Mesorectal fat area as a useful predictor of the difficulty of robotic-assisted laparoscopic total mesorectal excision for rectal cancer
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.
KeywordsRectal 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.
- 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. https://doi.org/10.1007/s10147-017-1101-6 PubMedCentralGoogle Scholar
- 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):642–649CrossRefPubMedGoogle Scholar
- 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):31–38CrossRefPubMedGoogle Scholar
- 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):915–919CrossRefPubMedGoogle Scholar
- 20.Brierley JD, Gospodarowicz. MK, Wittekind C (2017) TNM classification of malignant tumours, 8th Edn. Wiley-Blackwell, OxfordGoogle Scholar
- 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):1024–1032CrossRefPubMedGoogle Scholar
- 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. https://doi.org/10.1097/SLA.0000000000002653 Google Scholar
- 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):3210–3215CrossRefPubMedGoogle Scholar