Initial surgical experience in laparoscopic total mesorectal excision for middle and lower third rectal cancer: short-term results.

Introduction: Total mesorectal excision (TME) of the rectum has been advocated as the gold standard surgical treatment of middle and lower third rectal cancer. Laparoscopy has gained acceptance among surgeons in the treatment of colon malignancies, while scepticism exists about laparoscopic TME in terms of safety and its oncological adequacy.

Objective: To evaluate the impact of laparoscopic TME on surgical and oncological outcome in a group of consecutive unselected patients.

Methods: One hundred and thirty-two patients with middle or inferior rectal cancer were admitted to our unit and underwent TME from December 1998 to February 2008. Eighty-nine patients were approached with laparoscopy. Patients staged cT3/4 cTxN+ or uTxN+ were submitted to neoadjuvant treatment. Postoperative complications and oncological outcomes were registered.

Results: In the laparoscopic group 80 anterior resections (including 4 intersphincteric resections and manual colo- anal anastomosis) and 9 abdominal-perineal resections were performed. 33.3% of patients were enrolled in "long-course" neoadjuvant chemo-radiotherapy (partial and complete response rates 88.2% and 11.8%, respectively). Protective lateral ileostomy was performed in 72% of patients. Mean operative time was 254.3+/-38.3 min and mean blood loss was 215+/-180 ml. Conversion rate was 12.7%. Morbidity rate was 39.3% without mortality. The rate of anastomotic leaks was 13.48%, reoperation rate 13.48%, recovery rate 3.1+/-1.4 days and hospital stay 10.4+/-4.6 days. Concerning adequacy of oncologic resection, mean distance of the tumour from the anal verge was 4.3+/-2.2 cm. Nodal sampling of 12.4+/-4.8 were obtained. Six patients (6/89, 6.74%) had a R1 margin: 3 distal and 3 circumferential. Median follow-up was 29 months and local recurrence rate was 5.79%. Four-year cumulative overall survival was 78% and disease-free survival was 63% (Kaplan-Meier method).

Conclusions: Laparoscopic approach for rectal tumour is a technically demanding procedure, but it is oncologically safe.