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Introduction: Total mesorectal excision (TME) has offered the lowest recurrence rates and best survival in rectal cancer patients. Recently several multi‐centre trials have demonstrated the feasibility of laparoscopic colonic resections for cancer. However the technical difficulties and lack of supporting data has prevented surgeons from attempting laparoscopic TME for operable rectal cancer. We present a video demonstration of lap TME technique performed at our unit for rectal cancer resections. Methods: The surgical technique involves using two 10 mm and two 5 mm ports to perform rectal resections. Adherence to advanced oncological principles like high tie of IMA and IMV is the rule. Splenic flexure is routinely mobilised for mid to low rectal cancers. Total mesorectal excision is performed using diathermy hook. Rectal washout is performed before transection of the rectum using lap stapler device. Results: Between October 2006–December 2007, 30 rectal cancers have been operated laparoscopically at our institution using this technique. There were four APER and 26 anterior resections. The median age was 72 years with a median BMI of 25. Median operative time was 235 min with a median hospital stay of 7 days. There were no leaks. Conclusions: With proper training and experience, laparoscopic rectal cancer resection is technically feasible and safe to perform with good oncological outcomes.
In 1901, George Kelling performed the first experimental laparoscopy by insufflating air into the peritoneum of a dog, visualising the cavity with a cystoscope.1 Although the first publications on laparoscopy appeared from a French surgeon, Raoul Palmer, the leading pioneer of laparoscopic surgery was Professor Kurt Semm.2 Despite initial ridicule, he persisted with his innovative ideas on minimally invasive surgery from the 1960s and went on to perform the first laparoscopic appendicectomy in the 1980s.3 The first laparoscopic cholecystectomy was performed by Muhe in 19854 but limits in instrumentation meant the first laparoscopic colonic resections were not performed until 5 years later, a laparoscopic right hemicolectomy by Jacobs.5 Later that year, Fowler performed the first laparoscopic sigmoid resection6 and this was followed soon after by the first resection of a rectal cancer by Leahy.7
As obesity becomes more prevalent, it presents a technical challenge for minimally invasive colorectal resection surgery. Various studies have examined the clinical outcomes of obese surgical patients. However, morbidly obese patients (BMI ≥ 35) are becoming increasingly more common. This study aims to investigate the short-term surgical outcomes of morbidly obese patients undergoing minimal-invasive colorectal surgery and compare them with both obese (30 ≤ BMI < 35) and non-obese patients (BMI < 30). Patients from three centres who received minimally invasive colorectal surgical resections between 2006 and 2016 were identified from prospectively collected databases. The baseline characteristics and surgical outcomes of morbidly obese, obese and non-obese patients were analysed. A total of 1386 patients were identified, 84 (6%) morbidly obese, 246 (18%) obese and 1056 (76%) non-obese. Patients' baseline characteristics were similar for age, operating surgeon, surgical approach but differed in terms of ASA grade and gender. There was no difference in conversion rate, length of stay, anastomotic leak rate and 30-day readmission, reoperation and mortality rates. Operation time and blood loss were different across the 3 groups (morbidly obese vs obese vs non-obese: 185 vs 188 vs 170 min, p = 0.000; 20 vs 20 vs 10 ml, p = 0.003). In patients with malignant disease there was no difference in lymph node yield or R0 clearance. Univariate and multivariate linear regression analysis showed that for every one-unit increase in BMI operative time increases by roughly 2 min (univariate 2.243, 95% CI 1.524–2.962; multivariate 2.295; 95% CI 1.554–3.036). Univariate and multivariate binary logistic regression analyses showed that BMI does not affect conversion or morbidity and mortality. The increased technical difficulty encountered in obese and morbidly obese patients in minimally invasive colorectal surgery results in higher operative times and blood loss, although this is not clinically significant. However, conversion rate and post-operative short-term outcomes are similar between morbidly obese, obese and non-obese patients.
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