Laparoscopic Exposure of Critical Anatomy in Rectal Cancer Surgery: Techniques and Examples

  • Haane Massarotti
  • Steven D. Wexner


Laparoscopic colorectal surgery has considerably evolved over the past 20 years, with the development of an organized approach to performing laparoscopic colorectal surgery. During the past few decades, there have been significant improvements in outcome for rectal cancer with the introduction of total mesorectal excision (TME) for resection of low and mid rectal cancers. While laparoscopic colectomy for colon cancer is highly accepted, there has been a slower progression to acceptance of laparoscopic proctectomy for rectal cancer. Laparoscopic resection of rectal cancer has been primarily performed by highly experienced laparoscopic colorectal surgeons and has achieved acceptable short-term outcomes and long-term safety. However, with the proper technique and experience, laparoscopy offers superb visualization of the pelvic cavity, allowing for meticulous rectal mobilization and resection.


Laparoscopy Critical anatomy Rectal cancer surgery Total mesorectal excision 


  1. 1.
    Jacobs M, Verdeja JC, Goldstein HS. Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc. 1991;1(3):144–50.PubMedGoogle Scholar
  2. 2.
    Cologne KG, Senagore AJ. Development of Minimally invasive colorectal surgery: History, evidence, learning curve, and current adaptation. In: Bardakciglu O, editor. Advanced techniques in Minimally invasive and robotic colorectal surgery. New York, NY: Springer; 2015. p. 3–6.Google Scholar
  3. 3.
    Cologne KG, Senagore AJ. Proctectomy and rectopexy: laparoscopic approach. In: Bardakicioglu O, editor. Advanced techniques in minimally invasive and robotic colorectal surgery. New York, NY: Springer; 2015. p. 151–62.Google Scholar
  4. 4.
    Lau WY, Leow C, Li AK. Surgical history: history of endoscopic and laproscopic surgery. World J Surg. 1997;21:444–53.CrossRefPubMedGoogle Scholar
  5. 5.
    Champagne BJ. Management of rectal cancer. In: Bailey R, editor. Colorectal surgery. Philadelphia, PA: Elsevier Saunders; 2013.Google Scholar
  6. 6.
    Pollett WG, Nicholls RJ. The relationship between the extent of distal clearance and survival and local recurrence rates after curative anterior resection for carcinoma of the rectum. Ann Surg. 1983;198:159–63.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Phillips RK, Hittinger R, Blesovsky L, Fry JS, Fielding LP. Local recurrence following curative surgery for large bowel cancer: the overall picture. Br J Surg. 1984;71:6–12.Google Scholar
  8. 8.
    Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Lancet. 1986;328:996–9.CrossRefGoogle Scholar
  9. 9.
    Williams NS, Dixon MF, Johnston D. Reappraisal of the 5 centimeter rule of distal excision due to inadequate surgical resection. Br J Surg. 1983;70(3):150–4.CrossRefPubMedGoogle Scholar
  10. 10.
    Monson JRT, Weiser MR, Buie WD, et al. Practice parameters for the Management of Rectal Cancer (revised). Dis Colon Rectum. 2013;56(5):535–50.CrossRefPubMedGoogle Scholar
  11. 11.
    Bernstein TE, Endreseth BH, Romundstad P, Wibe A. Norweigian colorectal cancer registry. What is a safe distal resection margin in rectal cancer patients treated by low anterior resection without preoperative radiotherapy? Color Dis. 2012;14(2):e48–55.CrossRefGoogle Scholar
  12. 12.
    Fitzgerald TL, Brinkley J, Zervos EE. Pushing the envelope beyond a centimter in rectal cancer: oncologic implications of close, but negative margins. J Am Coll Surg. 2011;213(5):589–95.CrossRefPubMedGoogle Scholar
  13. 13.
    Bokey EL. Carcinoma of the rectum. In: Corman RB, Corman ML, editors. Corman’s colon and rectal surgery, Sixth Edition. 6th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2013.Google Scholar
  14. 14.
    Heald RJ, Ryall R. Recurrent cancer after restorative resection of the rectum. Br Med J (Clin Res Ed). 1982;284:826–7.CrossRefGoogle Scholar
  15. 15.
    Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery- the clue to pelvic recurrence? Br J Surg. 1982;69(10):613–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Martling AL, Holm T, Rutqvist LE, Moran BJ, Heald RJ, Cedemark B. Effect of surgical training programme on outcome of rectal cancer in the county of Stockholm. Stockholm colorectal cancer study group, Basingstoke bowel cancer research project. Lancet. 2000;356(9224):93–6.CrossRefPubMedGoogle Scholar
  17. 17.
    Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision in the operative treatment of carcnoma of the rectum. J Am Coll Surg. 1995;181(4):335–46.PubMedGoogle Scholar
  18. 18.
    Hill GL, Rafique M. Extrafascial excision of the rectum for rectal cancer. Br J Surg. 1998;85(6):809–12.CrossRefPubMedGoogle Scholar
  19. 19.
    Killingback M, Barron P, Dent OF. Local recurrence after curative resection of cancer of the rectum without total mesorectal excision. Dis Colon Rectum. 1991;44(4):473–83. discussion 483-486CrossRefGoogle Scholar
  20. 20.
    Lindsey I, Mortensen NJ. Iatrogenic impotance and rectal dissection. Br J Surg. 2002;89(12):1493–4.CrossRefPubMedGoogle Scholar
  21. 21.
    Moriya Y, Sugihara K, Akasu T, Fujita S. Nerve-sparing surgery with lateral node dissectoin for advanced low rectal cancer. Eur J Cancer. 1995;31A(7–8):1229–32.CrossRefPubMedGoogle Scholar
  22. 22.
    Nagtegaal ID, van de Velde CJ, van der Worp E, Kapiteijn E, Quirke P, van Krieken JH. Cooperative clinical investigators of the Dutch colorectal cancer group. Macroscopic evaluation of rectal cancer resection specimen: clinical signifiance of the pathologist in quality control. J Clin Oncol. 2002;20:1729–34.CrossRefPubMedGoogle Scholar
  23. 23.
    Goldstein NS. Lymph node recoveries from 2427 pT3 colorectal resection specimens spanning 45 yearsL recommendations for a minimum number of recovered lymph nodes based on predictive probabilities. Am J Surg Pathol. 2002;26(2):179–89.CrossRefPubMedGoogle Scholar
  24. 24.
    Le Voyer TE, Sigurdson ER, Hanlon AL, Mayer RJ, Macdonald JS, Catalano PJ, Haller DG. Colon Cancer survival is associated with increasing number of lymph nodes analyzed: a second survey of intergroup trial INT-0089. J Clin Oncol. 2003;21:2912–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Araghizadeh F, Abdelnaby A. Anatomy and physiology. In: Bailey R, editor. Colorectal surgery. Philadelphia, PA: Elsevier Saunders; 2013.Google Scholar
  26. 26.
    Jorge J, Habr-Gama A. Anatomy and embryology. In: Beck DE, Roberts PL, editors. The ASCRS Textbook of colon and rectal surgery. 2nd ed. New York, NY: Springer; 2011.Google Scholar
  27. 27.
    Bashankaev B, Seo C, Wexner SD. Laproscopic low anterior resection. In: Wexner SD, Fleshman JW, editors. Master techniques in general surgery: colon and rectal surgery, abdominal operations. Philadelphia, PA: Lippincott Williams and Wilkins; 2012.Google Scholar
  28. 28.
    Landmann RG. Intersphincteric restorative proctocolectomy for malignant disease. In: Wexner SD, Fleshman JW, editors. Master technicques in general surgery: colon and rectal surgery, abdominal operations. Philadelphia, PA: Lippincott Williams and Wilkins; 2012.Google Scholar
  29. 29.
    Taffinder N, Smith SG, Huber J, Russell RC, Darzi A. The effect of a second-generation 3D endoscope on the laparoscopic precision of novices and experienced surgeons. Surg Endosc. 1999;13(11):1087–92.CrossRefPubMedGoogle Scholar
  30. 30.
    Wilhelm D, Reiser S, Kohn N, Witte M, Leiner U, Muhlbach L, et al. Comparitive evaluation of HD 2D/3D laparoscopic monitors and benchmarking to a theoretical ideal 3D psuedodisplay: even well-experienced laparoscopists. Surg Endosc. 2014;28(8):2387–97.CrossRefPubMedGoogle Scholar
  31. 31.
    Schwaitzberg SD. Imaging systems in minimially invasive surgery. In: Swantstrom LL, Soper NJ, editors. Mastery of endoscopic and laparoscopic surgery. Philadelphia, PA: Lippincott Williams and Wilkins; 2014. p. 47–61.Google Scholar
  32. 32.
    Nakajima K, Milsom JW, Bohm B. Equipment and instrumentation. In:Laparoscopic colorectal surgery. 2nd ed. New York, NY: Springer; 2006. p. 10–30.CrossRefGoogle Scholar
  33. 33.
    Sorenson SM, Savran MM, Konge L, Bjerrum F. Three-dimensional versus two-dimensional vision in laparoscopy: a systematic review. Surg Endosc. 2016;30:11–23. ebut ahead of printCrossRefGoogle Scholar
  34. 34.
    Wagner OJ, Hagen M, Kurmann A, Horgan S, Candinas D, Vorburger SA. Three-dimensional vision enhances task performance independently of the surgical method. Surg Endosc. 2012;26:2961–8.CrossRefPubMedGoogle Scholar
  35. 35.
    Kunert W, Storz P, Kirschniak A. For 3D laparoscopy: a step toward advanced surgical navigation: how to get maximum benefit from 3D vision. Surg Endosc. 2013;27:696–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Bergamaschi RC, Larach SW, Pigazzi A, Marecik S, Valsdottir EB, Amrani S. Laparoscopic Colon and Rectal surgery. In: Corman ML, Bergamaschi RC, Nicholls RJ, Fazio VW, editors. Corman's colon and rectal surgery. 6th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2013.Google Scholar
  37. 37.
    Bleday R. Surgical treatment of rectal cancer. In: Beck DE, Roberts PL, Saclarides TJ, Senagore AJ, Stamos MJ, Wexner SD, editors. The ASCRS textbook of colon and rectal surgery. 2nd ed. New York, NY: Springer; 2011.Google Scholar
  38. 38.
    Brown CJ, Fenech D, McLeod RS. Reconstructive techniques after rectal resction for rectal cancer. Cochrane Database Syst Rev. 2008;16(2):CD006040.Google Scholar

Copyright information

© Springer Japan 2018

Authors and Affiliations

  1. 1.Department of Colorectal SurgeryCleveland Clinic FloridaWestonUSA

Personalised recommendations