Dear Sir,

In their systematic review and meta-analysis of 11 randomized controlled trials (RCT), Pedziwiatr et al. [1] concluded that there was no difference in oncological outcomes between laparoscopic and open proctectomy for rectal cancer. Previous enthusiasm for a laparoscopic approach has been recently counterbalanced by the increased rates of circumferential resection margin involvement secondary to the impaired ergonomics of non-articulating laparoscopic instruments in the confined space of the pelvis [2].

In their review, Pedziwiatr et al. provided (1) no data from 1966 to 2005; (2) no data on tumor distance from the anal verge; (3) no data on the quality of total mesorectal excision (TME) for 6 of 11 RCTs; (4) no emphasis on the non-inferiority design of the RCTs utilizing intent-to-treat analysis.

In a recent meta-analysis, Martinez-Perez et al. [3] reported that laparoscopic proctectomy for rectal cancer was inferior to its open counterpart in terms of TME quality. Martinez-Perez et al. [3] drew such conclusions analyzing nearly complete together with incomplete TME quality specimens as compared to complete. Conversely, Pedziwiatr et al. [1] analyzed nearly complete with complete TME quality and compared them to incomplete cases. It is our opinion that the nearly complete resected specimens in Nagtegaal et al.'s [4] three-tiered classification were not intended to be considered as complete TME quality.