Superior pathologic and clinical outcomes after minimally invasive rectal cancer resection, compared to open resection



While the ACOSOG and ALaCaRT trials found that laparoscopic resections for rectal cancer failed to demonstrate non-inferiority of pathologic outcomes when compared with open resections, the COLOR II and COREAN studies demonstrated non-inferiority of clinical outcomes, leading to uncertainty regarding the value of minimally invasive (MIS) techniques in rectal cancer surgery. We analyzed differences in pathologic and clinical outcomes between open versus MIS resections for rectal cancer.


We identified patients who underwent resection for stage II or III rectal adenocarcinoma from the National Cancer Database (2010–2015). Surgical approach was categorized as open or MIS (laparoscopic or robotic). Logistic regression and Cox proportional hazard analysis were used to assess differences in outcomes and survival. Analysis was performed in an intention-to-treat fashion.


A total of 31,190 patients who underwent rectal adenocarcinoma resection were identified, of whom 52.8% underwent open resection and 47.2% underwent MIS resection (31.0% laparoscopic, 16.2% robotic). After adjustment for patient, tumor, and institutional characteristics, MIS approaches were associated with significantly decreased risk of positive circumferential resection margins (OR 0.82, 95% CI 0.72–0.94), increased likelihood of harvesting ≥ 12 lymph nodes (OR 1.12, 95% CI 1.04–1.21), shorter length of stay (OR 0.57, 95% CI 0.53–0.62), and improved overall survival (HR 0.90, 95% CI 0.83–0.98).


MIS approaches to rectal cancer resection were associated with improved pathologic and clinical outcomes when compared to the open approach. In this nationwide, facility-based sample of cancer cases in the United States, our data suggest superiority of MIS techniques for rectal cancer treatment.

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GCL was supported by the National Institutes of Health T32 Research Training in Alimentary Tract Surgery Grant DK007754-13.

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Corresponding authors

Correspondence to Hiroko Kunitake or Motaz Qadan.

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Grace C. Lee was supported by the NIH T32 Research Training in Alimentary Tract Surgery grant DK007754-13. Liliana G. Bordeianou is a consultant for Ethicon and legal consultant for CRICO, receives royalty fees from Up-to-Date, and receives research support from 11 Health, all outside the submitted work. Todd D. Francone is a consultant for Intuitive, outside the submitted work. Lawrence S. Blaszkowsky, Robert N. Goldstone, Rocco Ricciardi, and Hiroko Kunitake have no conflicts of interest or financial ties to disclose. Motaz Qadan is a consultant for Olympus, outside the submitted work.

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Hiroko Kunitake and Motaz Qadan are co-senior authors.

Appendix 1: Definitions of commission on cancer facility types and facility regions

Appendix 1: Definitions of commission on cancer facility types and facility regions

Definitions of Commission on Cancer facility types
 Community Cancer Program Facility accessions 100–500 newly diagnosed cancer cases each year. Training resident physicians is optional
 Comprehensive Community Cancer Program Facility accessions > 500 newly diagnosed cancer cases each year. Training resident physicians is optional
 Academic/Research Program Facility accessions > 500 newly diagnosed cancer cases each year. Facility participates in training resident physicians in at least four program areas, including internal medicine and general surgery
 Integrated Network Cancer Program Multiple facilities providing integrated cancer care. At least one facility is a hospital. Training resident physicians is optional, and there is no minimum caseload requirement
States contained in each United States facility region
 New England CT, MA, ME, NH, RI, VT
 Middle Atlantic NJ, NY, PA
 South Atlantic DC, DE, FL, GA, MD, NC, SC, VA, WV
 East North Central IL, IN, MI, OH, WI
 East South Central AL, KY, MS, TN
 West North Central IA, KS, MN, MO, ND, NE, SD
 West South Central AR, LA, OK, TX
 Mountain AZ, CO, ID, MT, NM, NV, UT, WY
 Pacific AK, CA, HI, OR, WA

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Lee, G.C., Bordeianou, L.G., Francone, T.D. et al. Superior pathologic and clinical outcomes after minimally invasive rectal cancer resection, compared to open resection. Surg Endosc 34, 3435–3448 (2020).

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  • Rectal adenocarcinoma
  • Minimally invasive
  • Laparoscopic
  • Robotic
  • Survival