Value of multi-disciplinary input into laparoscopic management of rectal cancer - An observational study

Table 1 Stepwise approach to rectal dissection

1	Port positions: 10-12 mm - sub-umbilical, RUQ (camera), RIF and LIF; patient in Lloyd-Davies position
2	Omentum to supracolic compartment and small bowel stacking
3	Identify right ureter
4	Start medial dissection at the promontory
5	Identify left ureter, then left gonadal, pelvic nerves
6	Protect left ureter with surgicel® and Pedicle dissection
7	Identify ureter through both windows of mesentery either side of pedicle
8	Transect pedicle, confirm haemostasis
9	Left lateral dissection, identify left ureter and proceed up to peritoneal reflection; IMV high tie and splenic flexure mobilisation, if required
10	Mesorectal Dissection and preparation of rectum for division1
	Right mesorectal dissection up to peritoneal reflection
	Posterior dissection (presacral plane down to levator), keep left ureter in view
	Divide peritoneal reflection anteriorly and dissect till seminal vesicles/vaginal fornix
	Complete both lateral dissection, identify the ureters all the way
	Anterior dissection keeping to the plane just posterior to the vesicles/vagina
	Rectal Cross stapling (achieve antero-posterior staple line) or proceed to perineal dissection1
11	Intra-corporeal cross stapling of rectum at appropriate level protecting lateral and anterior structures and Grasp stapled end of specimen
12	Left iliac fossa port extended as a transverse incision for specimen delivery; protect wound and deliver specimen by the stapled end
13	Complete mesenteric ligation, proximal bowel division and prepare proximal bowel for anastomosis
14	Close wound, re-establish pneumoperitoneum
15	Intra-corporeal bowel anastomosis with no tension, no twist and vital structures protected
16	Close incisions

¹In patients undergoing laparoscopic abdomino-perineal excision, the left sided port is placed at the site of the planned colostomy and the laparoscopic dissection stopped at the mid rectal level, the proximal colon divided intra-corporeally with a stapler and proceed to a wide excision of the anal sphincter complex to obtain a cylindrical specimen.

Table 2 Operations (n = 133)

Operations	Laparoscopic (conversion)	Open	Total
Anterior resections	66 (2)	6	72
TME	4		4
TME + I	25 (1)	4	29
TME Hartmann’s	1 (1)		1
APER	26 (2)	1	27

TME: Total mesorectal excision; APER: Abdomino-perineal excision.

Table 3 Post-op stage (n = 133)

Post-op stage	n
R0 resection	124
R1 resection (CRM + ve)	9
R2 resection	0
T1	14
T2	42
T3	58
T4	17
N0	85
N1	31
N2	15

Table 4 Comparison of circumferential resection margin positive

Type of operation	Dutch TME trial[6]	CLASICC trial[5]	MR CRO7 trial[9]	Our series
Sphincter saving resection	13%	10%	8%	3% (4/106)
APER	29%	21%	17%	18% (5/27)

TME: Total mesorectal excision; APER: Abdomino-perineal excision.

Table 5 Comparison of local recurrence

	Meta-analysis[4] (n = 1544)	Dutch TME trial[6] (n = 1586)	CLASICC trial[5] (n = 400)	MRC CR07 trial[9] (n = 1350)	Our series (n = 133)
Local recurrence	13%	8%	6.80%	7%	3% (4/133)

TME: Total mesorectal excision.