Emerging role of laparoscopic and robotic surgery for rectal cancers

The surgical management of rectal cancers is in a rapid phase of evolution that will increasingly deploy minimally invasive surgical (MIS) techniques. In this issue of Annals of Surgical Oncology are two articles about MIS approaches for rectal cancer, one comparing open versus laparoscopic proctectomy and the other comparing laparoscopic versus robotic approaches. These articles offer an opportunity to encourage the systematic validation of these technologies through clinical trials as they are increasingly adopted for colorectal surgery. Over the past decade, urologists have made great strides in implementing robotic surgery for pelvic procedures, although the surgical oncology and colorectal surgery communities have not yet embraced this technology at the same pace. For example, in 2007, approximately 50,000 radical prostatectomies were performed with the Da Vinci robot system in the United States, or approximately 60% of radical prostatectomies. In general, the reported results of robotic prostatectomy demonstrated less blood loss and shorter length of hospital stay; although the potency and continence rates were comparable, a trend was noted toward a faster return of functional outcomes. The gynecological community has also started to use the robotic system, which has shown similar results to those described by urologists for prostatectomy. That is, compared with open or laparoscopic techniques, robotic surgery for radical hysterectomy resulted in less blood loss, fewer postoperative complications, and shorter length of stay. Last year, Mattias Soop and Heidi Nelson, in an editorial published in Annals of Surgical Oncology, wrote, ‘‘we believe that the cumulative literature now supports an equipoise on short term advantages and long-term oncologic outcomes (for laparoscopic proctectomy for cancer), making the case for large prospective randomized trials.’’ Since the COST study group published its results in 2004 showing equivalence in oncologic outcomes between open and laparoscopic resection of colon cancer, the use of laparoscopic techniques for colon cancer has become popular and has now expanded to include rectal cancer patients. The data for rectal cancer is still being generated, but the randomized Conventional Versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC trial), as well as several retrospective studies, demonstrate that the use of laparoscopic techniques has at least equivalent oncologic outcomes compared with an open laparotomy approach. For example, in this issue of Annals of Surgical Oncology is a multivariate analysis of 421 consecutive patients with stage II and stage III rectal cancer conducted by Law and colleagues who retrospectively compared outcomes of open versus laparoscopic resection. Laparoscopic resection was associated with significantly less blood loss and shorter hospital stay and was one of the independent significant factors associated with better survival (P = .03, hazard ratio .558, 95% confidence interval .339–.969). Ng and colleagues from Hong Kong reported last year in Annals of Surgical Oncology the preliminary results of a randomized trial comparing open versus laparoscopic abdominoperineal resection in 99 rectal cancer patients with a follow-up of 90 months. Their results showed that postoperative recovery was better after laparoscopic surgery, and 5-year survival was identical. These results are consistent with other studies showing that laparoscopic colon resection provides better perioperative outcomes compared with open laparotomy, including decreased postoperative pain, earlier return to normal physical function, quicker return to bowel function, and shorter hospital stays. Society of Surgical Oncology 2009