Surgical Endoscopy

, Volume 33, Issue 2, pp 557–566 | Cite as

Mesorectal fat area as a useful predictor of the difficulty of robotic-assisted laparoscopic total mesorectal excision for rectal cancer

  • Yusuke Yamaoka
  • Tomohiro YamaguchiEmail author
  • Yusuke Kinugasa
  • Akio Shiomi
  • Hiroyasu Kagawa
  • Yushi Yamakawa
  • Akinobu Furutani
  • Shoichi Manabe
  • Kakeru Torii
  • Kohei Koido
  • Keita Mori



Various predictors of the difficulty of total mesorectal excision for rectal cancer have been described. Although a bulky mesorectum was considered to pose technical difficulties in total mesorectal excision, no studies have evaluated the influence of mesorectum morphology on the difficulty of total mesorectal excision. Mesorectal fat area at the level of the tip of the ischial spines on magnetic resonance imaging was described as a parameter characterizing mesorectum morphology. This study aimed to evaluate the influence of clinical and anatomical factors, including mesorectal fat area, on the difficulty of total mesorectal excision for rectal cancer.


This study enrolled 98 patients who underwent robotic-assisted laparoscopic low anterior resection with total mesorectal excision for primary rectal cancer, performed by a single expert surgeon, between 2010 and 2015. Magnetic resonance imaging-based pelvimetry data were collected. Linear regression was performed to determine clinical and anatomical factors significantly associated with operative time of the pelvic phase, which was defined as the time interval from the start of rectal mobilization to the division of the rectum.


The median operative time of the pelvic phase was 68 min (range 33–178 min). On univariate analysis, the following variables were significantly associated with longer operative time of the pelvic phase: male sex, larger tumor size, larger visceral fat area, larger mesorectal fat area, shorter pelvic outlet length, longer sacral length, shorter interspinous distance, larger pelvic inlet angle, and smaller angle between the lines connecting the coccyx to S3 and to the inferior middle aspect of the pubic symphysis. On multiple linear regression analysis, only larger mesorectal fat area remained significantly associated with longer operative time of the pelvic phase (p = 0.009).


Mesorectal fat area may serve as a useful predictor of the difficulty of total mesorectal excision for rectal cancer.


Rectal cancer Total mesorectal excision Robotic surgery Surgical difficulty Mesorectal fat area Operative time 



No funding was received for this research.

Compliance with ethical standards


Drs. Yusuke Yamaoka, Tomohiro Yamaguchi, Yusuke Kinugasa, Akio Shiomi, Hiroyasu Kagawa, Yushi Yamakawa, Akinobu Furutani, Shoichi Manabe, Kakeru Torii, Kohei Koido, and Keita Mori have no conflicts of interest or financial ties to disclose.


  1. 1.
    Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery-the clue to pelvic recurrence? Br J Surg 69:613–616CrossRefGoogle Scholar
  2. 2.
    Watanabe T, Muro K, Ajioka Y, Hashiguchi Y, Ito Y, Saito Y, Hamaguchi T, Ishida H, Ishiguro M, Ishihara S, Kanemitsu Y, Kawano H, Kinugasa Y, Kokudo N, Murofushi K, Nakajima T, Oka S, Sakai Y, Tsuji A, Uehara K, Ueno H, Yamazaki K, Yoshida M, Yoshino T, Boku N, Fujimori T, Itabashi M, Koinuma N, Morita T, Nishimura G, Sakata Y, Shimada Y, Takahashi K, Tanaka S, Tsuruta O, Yamaguchi T, Yamaguchi N, Tanaka T, Kotake K, Sugihara K; Japanese Society for Cancer of the Colon and Rectum (2017) Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2016 for the treatment of colorectal cancer. Int J Clin Oncol. Google Scholar
  3. 3.
    Sun WM, Read NW, Katsinelos P, Donnelly TC, Shorthouse AJ (1994) Anorectal function after restorative proctocolectomy and low anterior resection with coloanal anastomosis. Br J Surg 81(2):280–284CrossRefGoogle Scholar
  4. 4.
    Havenga K, Enker WE, McDermott K, Cohen AM, Minsky BD, Guillem J (1996) Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J Am Coll Surg 182(6):495–502Google Scholar
  5. 5.
    Maslekar S, Sharma A, Macdonald A, Gunn J, Monson JR, Hartley JE (2007) Mesorectal grades predict recurrences after curative resection for rectal cancer. Dis Colon Rectum 50(2):168–175CrossRefGoogle Scholar
  6. 6.
    Salerno G, Daniels IR, Brown G, Norman AR, Moran BJ, Heald RJ (2007) Variations in pelvic dimensions do not predict the risk of circumferential resection margin (CRM) involvement in rectal cancer. World J Surg 31(6):1313–1320CrossRefGoogle Scholar
  7. 7.
    Baik SH, Kim NK, Lee KY, Sohn SK, Cho CH, Kim MJ, Kim H, Shinn RK (2008) Factors influencing pathologic results after total mesorectal excision for rectal cancer: analysis of consecutive 100 cases. Ann Surg Oncol 15(3):721–728CrossRefGoogle Scholar
  8. 8.
    Targarona EM, Balague C, Pernas JC, Martinez C, Berindoague R, Gich I, Trias M (2008) Can we predict immediate outcome after laparoscopic rectal surgery? Multivariate analysis of clinical, anatomic, and pathologic features after 3-dimensional reconstruction of the pelvic anatomy. Ann Surg 247(4):642–649CrossRefGoogle Scholar
  9. 9.
    Akiyoshi T, Kuroyanagi H, Oya M, Konishi T, Fukuda M, Fujimoto Y, Ueno M, Miyata S, Yamaguchi T (2009) Factors affecting the difficulty of laparoscopic total mesorectal excision with double stapling technique anastomosis for low rectal cancer. Surgery 146(3):483–489CrossRefGoogle Scholar
  10. 10.
    Killeen T, Banerjee S, Vijay V, Al-Dabbagh Z, Francis D, Warren S (2010) Magnetic resonance (MR) pelvimetry as a predictor of difficulty in laparoscopic operations for rectal cancer. Surg Endosc 24(12):2974–2979CrossRefGoogle Scholar
  11. 11.
    Kim JY, Kim YW, Kim NK, Hur H, Lee K, Min BS, Cho HJ (2011) Pelvic anatomy as a factor in laparoscopic rectal surgery: a prospective study. Surg Laparosc Endosc Percutan Tech 21(5):334–339CrossRefGoogle Scholar
  12. 12.
    Chen W, Li Q, Fan Y, Li D, Jiang L, Qiu P, Tang L (2016) Factors predicting difficulty of laparoscopic low anterior resection for rectal cancer with total mesorectal excision and double stapling technique. PLoS ONE 11(3):e0151773CrossRefGoogle Scholar
  13. 13.
    Chen B, Zhang Y, Zhao S, Yang T, Wu Q, Jin C, He Y, Wang Z (2016) The impact of general/visceral obesity on completion of mesorectum and perioperative outcomes of laparoscopic TME for rectal cancer: A STARD-compliant article. Medicine (Baltimore) 95(36):e4462CrossRefGoogle Scholar
  14. 14.
    Zhou XC, Su M, Hu KQ, Su YF, Ye YH, Huang CQ, Yu ZL, Li XY, Zhou H, Ni YZ, Jiang YI, Lou Z (2016) CT pelvimetry and clinicopathological parameters in evaluation of the technical difficulties in performing open rectal surgery for mid-low rectal cancer. Oncol Lett 11(1):31–38CrossRefGoogle Scholar
  15. 15.
    Park IJ, Yu CS, Lim SB, Lee JL, Kim CW, Yoon YS, Park SH, Kim JC (2016) Is preoperative chemoradiotherapy beneficial for sphincter preservation in low-lying rectal cancer patients? Medicine (Baltimore) 95(18):e3463CrossRefGoogle Scholar
  16. 16.
    Dayal S, Battersby N, Cecil T (2017) Evolution of surgical treatment for rectal cancer: a review. J Gastrointest Surg 21(7):1166–1173CrossRefGoogle Scholar
  17. 17.
    Boyle KM, Chalmers AG, Finan PJ, Sagar PM, Burke D (2009) Morphology of the mesorectum in patients with primary rectal cancer. Dis Colon Rectum 52(6):1122–1129CrossRefGoogle Scholar
  18. 18.
    Lowry AC, Simmang CL, Boulos P, Farmer KC, Finan PJ, Hyman N, Killingback M, Lubowski DZ, Moore R, Penfold C, Savoca P, Stitz R, Tjandra JJ (2001) Consensus statement of definitions for anorectal physiology and rectal cancer: report of the Tripartite Consensus Conference on Definitions for Anorectal Physiology and Cancer R, Washington, D.C., May 1, 1999. Dis Colon Rectum 44(7):915–919CrossRefGoogle Scholar
  19. 19.
    Yamaoka Y, Kinugasa Y, Shiomi A, Yamaguchi T, Kagawa H, Yamakawa Y, Numata M, Furutani A (2017) Preoperative chemoradiotherapy changes the size criterion for predicting lateral lymph node metastasis in lower rectal cancer. Int J Colorectal Dis 32(11):1631–1637CrossRefGoogle Scholar
  20. 20.
    Brierley JD, Gospodarowicz. MK, Wittekind C (2017) TNM classification of malignant tumours, 8th Edn. Wiley-Blackwell, OxfordGoogle Scholar
  21. 21.
    Shiomi A, Kinugasa Y, Yamaguchi T, Kagawa H, Yamakawa Y (2016) Robot-assisted versus laparoscopic surgery for lower rectal cancer: the impact of visceral obesity on surgical outcomes. Int J Colorectal Dis 31(10):1701–1710CrossRefGoogle Scholar
  22. 22.
    Yamaguchi T, Kinugasa Y, Shiomi A, Tomioka H, Kagawa H, Yamakawa Y (2016) Robotic-assisted vs. conventional laparoscopic surgery for rectal cancer: short-term outcomes at a single center. Surg Today 46(8):957–962CrossRefGoogle Scholar
  23. 23.
    Kinugasa Y, Murakami G, Suzuki D, Sugihara K (2007) Histological identification of fascial structures posterolateral to the rectum. Br J Surg 94(5):620–626CrossRefGoogle Scholar
  24. 24.
    Kinugasa Y, Murakami G, Uchimoto K, Takenaka A, Yajima T, Sugihara K (2006) Operating behind Denonvilliers’ fascia for reliable preservation of urogenital autonomic nerves in total mesorectal excision: a histologic study using cadaveric specimens, including a surgical experiment using fresh cadaveric models. Dis. Colon Rectum 49(7):1024–1032CrossRefGoogle Scholar
  25. 25.
    Escal L, Nougaret S, Guiu B, Bertrand MM, de Forges H, Tetreau R, Thézenas S, Rouanet P (2018) MRI-based score to predict surgical difficulty in patients with rectal cancer. Br J Surg 105(1):140–146CrossRefGoogle Scholar
  26. 26.
    Yamaguchi T, Kinugasa Y, Shiomi A, Tomioka H, Kagawa H (2016) Robotic-assisted laparoscopic versus open lateral lymph node dissection for advanced lower rectal cancer. Surg Endosc 230(2):721–728CrossRefGoogle Scholar
  27. 27.
    Zhang X, Wei Z, Bie M, Peng X, Chen C (2016) Robot-assisted versus laparoscopic-assisted surgery for colorectal cancer: a meta-analysis. Surg Endosc 30(12):5601–5614CrossRefGoogle Scholar
  28. 28.
    Kim JY, Kim NK, Lee KY, Hur H, Min BS, Kim JH (2012) A comparative study of voiding and sexual function after total mesorectal excision with autonomic nerve preservation for rectal cancer: laparoscopic versus robotic surgery. Ann Surg Oncol 19(8):2485–2493CrossRefGoogle Scholar
  29. 29.
    Kim J, Baek SJ, Kang DW, Roh YE, Lee JW, Kwak HD, Kwak JM, Kim SH (2017) Robotic resection is a good prognostic factor in rectal cancer compared with laparoscopic resection: long-term survival analysis using propensity score matching. Dis Colon Rectum 60(3):266–273Google Scholar
  30. 30.
    Baek SJ, Kim CH, Cho MS, Bae SU, Hur H, Min BS, Baik SH, Lee KY, Kim NK (2015) Robotic surgery for rectal cancer can overcome difficulties associated with pelvic anatomy. Surg Endosc 29(6):1419–1424CrossRefGoogle Scholar
  31. 31.
    Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J, Moran B, Hanna GB, Mortensen NJ, Tekkis PP, TaTME Registry Collaborative (2017) Transanal total mesorectal excision: international registry results of the first 720 cases. Ann Surg 266(1):111–117CrossRefGoogle Scholar
  32. 32.
    Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J, Moran B, Hanna GB, Mortensen NJ, Tekkis PP, International TaTME Registry Collaborative (2018) Incidence and risk factors for anastomotic failure in 1594 patients treated by transanal total mesorectal excision: results from the International TaTME Registry. Ann Surg. Google Scholar
  33. 33.
    Deijen CL, Velthuis S, Tsai A, Mavroveli S, de Lange-de Klerk ES, Sietses C, Tuynman JB, Lacy AM, Hanna GB, Bonjer HJ (2016) COLOR III: a multicentre randomised clinical trial comparing transanal TME versus laparoscopic TME for mid and low rectal cancer. Surg Endosc 30(8):3210–3215CrossRefGoogle Scholar
  34. 34.
    Yamaguchi T, Kinugasa Y, Shiomi A, Sato S, Yamakawa Y, Kagawa H, Tomioka H, Mori K (2015) Learning curve for robotic-assisted surgery for rectal cancer: use of the cumulative sum method. Surg Endosc 29(7):1679–1685CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Yusuke Yamaoka
    • 1
  • Tomohiro Yamaguchi
    • 1
    • 2
    Email author
  • Yusuke Kinugasa
    • 1
    • 3
  • Akio Shiomi
    • 1
  • Hiroyasu Kagawa
    • 1
  • Yushi Yamakawa
    • 1
  • Akinobu Furutani
    • 1
  • Shoichi Manabe
    • 1
  • Kakeru Torii
    • 1
  • Kohei Koido
    • 1
  • Keita Mori
    • 4
  1. 1.Division of Colon and Rectal SurgeryShizuoka Cancer Center HospitalShizuokaJapan
  2. 2.Department of Gastroenterological SurgeryCancer Institute Hospital of the Japanese Foundation for Cancer ResearchTokyoJapan
  3. 3.Department of Colorectal SurgeryTokyo Medical and Dental University Medical HospitalTokyoJapan
  4. 4.Clinical Trial Coordination OfficeShizuoka Cancer Center HospitalShizuokaJapan

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