Laparoscopic Versus Robotic Versus Open Surgery for Rectal Cancer
A 64-year-old male completed neo-adjuvant chemo-radiotherapy for a cT3bN+ adenocarcinoma at 11 cm from the anal verge 5 weeks ago. Repeat MRI demonstrates tumor downsizing. He is aware that surgery involves open or minimally invasive approaches. He wants
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Laparoscopic Versus Robotic Versus Open Surgery for Rectal Cancer Campbell S. Roxburgh and Martin R. Weiser
Clinical Scenario A 64-year-old male completed neo-adjuvant chemo-radiotherapy for a cT3bN+ adenocarcinoma at 11 cm from the anal verge 5 weeks ago. Repeat MRI demonstrates tumor downsizing. He is aware that surgery involves open or minimally invasive approaches. He wants to return to work as soon as possible but above all wants surgery with the highest chance of “cure.” Question Which of the surgical approaches for rectal cancer resection (open vs. laparoscopic vs. robotic) results in the best outcomes? Background When choosing among operative approaches, outcome measures fall into two broad categories: (1) those related to short and long-term sequelae of the radical resection (surgical morbidity, return to function, and quality of life), and (2) those related to the disease process (recurrence, disease-free and overall survival). Both open and minimally invasive (laparoscopic and robotic) techniques may be employed to perform total mesorectal excision (TME) for rectal cancer. Here we aim to review outcomes for each approach to aid decision making. We make two comparisons: A. Compared with open surgery, does laparoscopic surgery result in better outcomes after rectal cancer treatment? (Table 46.1a) B. Compared with laparoscopic surgery, does robotic-assisted surgery result in better outcomes after rectal cancer treatment? (Table 46.1b) C.S. Roxburgh Memorial Sloan Kettering Cancer Center, New York, NY, USA M.R. Weiser, MD (*) Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA e-mail: [email protected] © Springer International Publishing Switzerland 2017 N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery, Difficult Decisions in Surgery: An Evidence-Based Approach, DOI 10.1007/978-3-319-40223-9_46
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C.S. Roxburgh and M.R. Weiser
Table 46.1 (a) Laparoscopic versus open surgery for rectal cancer and (b) robotic versus laparoscopic surgery for rectal cancer – PICO tables (a)
(b)
Patient population Rectal cancer, post neoadjuvant chemo- radiotherapy
Intervention
Comparator
Outcomes studied
Laparoscopically performed TME
Open TME
Patient population Rectal cancer, post neoadjuvant chemo- radiotherapy
Intervention
Comparator
Procedure related morbidity Length of stay, complications – grade 3/4/5, anastomotic leak, reoperation Oncologic CRM involvement, distal resection margin involvement, distance to CRM, distance to distal resection margin, LN yield, completeness of TME Disease specific survival, overall survival, local recurrence Outcomes studied
Robotically performed TME
Laparoscopically performed TME
Procedure related Length of stay, complications – grade 3/4/5, anastomotic leak, reoperation, cost, open conversion Oncologic CRM involvement, distal resection margin involvement, distance to CRM, distance to distal resection margin, LN yield, completeness of TME Disease specific survival, o
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