Skip to main content

Open versus minimally invasive surgery for rectal cancer: a single-center cohort study on 237 consecutive patients

Updates in Surgery volume 71, pages 493–504 (2019)Cite this article

Abstract

Minimally invasive surgery (MIS) is gaining popularity in rectal tumor treatment. However, contrasting data are available regarding its safety and efficacy. Our aim is to compare the open and MIS approaches for rectal cancer treatment. Two-hundred-thirty-seven patients were included: 113 open and 124 MIS rectal resections. After the propensity score matching analysis (PS), the cases were matched into 42 open and 42 MIS. Short- and long-term outcomes, and pathological findings were analyzed before and after PS. A further comparison of the same outcomes and costs was conducted between the laparoscopic and the robotic approaches. As a whole, a sphincter-preserving procedure was more frequently performed in the MIS group (110 vs 75 cases; p < 0.0001). The estimated blood loss during MIS was significantly lower than during open surgery [127 (± 92) vs 242 (± 122) mL; p < 0.0001], with clear advantages for the robotic approach over laparoscopy [113 (± 87) vs 147 (± 93) mL; p 0.01]. Complication rate was comparable between the two groups. A higher rate of CRM positivity was evidenced after open surgery (12.4% vs 1.7%; p 0.004). A higher number of lymph nodes was harvested in the MIS group [12.5 (± 6.4) vs 11 (± 5.6); p 0.04]. After PS, no difference in terms of perioperative outcomes was noted, with the only exception of a higher blood loss in the open approach [242 (± 122) vs 127 (± 92) mL; p < 0.0001]. For the matched cases, no difference in 5-year overall and disease-free survival was evidenced (p 0.50 and 0.88, respectively). Mean costs were higher for robotics as compared to laparoscopy [9812 (±1974)€ vs 9045 (± 1893)€; p 0.02]. MIS could be considered as a treatment option for rectal cancer. The PS study evidenced clear advantages in terms of estimated blood loss over the open surgery. Costs still remain the main limit for robotics.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2

References

  1. van der Pas MH, Haglind E, Cuesta MA, Fürst A, Lacy AM, Hop WC, Bonjer HJ, Group CcLoORIS (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14(3):210–218

    Article  PubMed  Google Scholar 

  2. Kang SB, Park JW, Jeong SY, Nam BH, Choi HS, Kim DW, Lim SB, Lee TG, Kim DY, Kim JS, Chang HJ, Lee HS, Kim SY, Jung KH, Hong YS, Kim JH, Sohn DK, Kim DH, Oh JH (2010) Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 11(7):637–645. https://doi.org/10.1016/S1470-2045(10)70131-5

    Article  PubMed  Google Scholar 

  3. Chen K, Cao G, Chen B, Wang M, Xu X, Cai W, Xu Y, Xiong M (2017) Laparoscopic versus open surgery for rectal cancer: a meta-analysis of classic randomized controlled trials and high-quality nonrandomized studies in the last 5 years. Int J Surg 39:1–10

    Article  PubMed  Google Scholar 

  4. Greenblatt DY, Rajamanickam V, Pugely AJ, Heise CP, Foley EF, Kennedy GD (2011) Short-term outcomes after laparoscopic-assisted proctectomy for rectal cancer: results from the ACS NSQIP. J Am Coll Surg 212(5):844–854

    Article  PubMed  PubMed Central  Google Scholar 

  5. Fleshman J, Branda M, Sargent DJ, Boller AM, George V, Abbas M, Peters WR Jr, Maun D, Chang G, Herline A, Fichera A, Mutch M, Wexner S, Whiteford M, Marks J, Birnbaum E, Margolin D, Larson D, Marcello P, Posner M, Read T, Monson J, Wren SM, Pisters PW, Nelson H (2015) Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA 314(13):1346–1355. https://doi.org/10.1001/jama.2015.10529

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Stevenson AR, Solomon MJ, Lumley JW, Hewett P, Clouston AD, Gebski VJ, Davies L, Wilson K, Hague W, Simes J, Investigators AL (2015) Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA 314(13):1356–1363. https://doi.org/10.1001/jama.2015.12009

    Article  CAS  PubMed  Google Scholar 

  7. Ng KH, Lim YK, Ho KS, Ooi BS, Eu KW (2009) Robotic-assisted surgery for low rectal dissection: from better views to better outcome. Singap Med J 50(8):763–767

    CAS  Google Scholar 

  8. Wexner SD, Bergamaschi R, Lacy A, Udo J, Brolmann H, Kennedy RH, John H (2009) The current status of robotic pelvic surgery: results of a multinational interdisciplinary consensus conference. Surg Endosc 23(2):438–443. https://doi.org/10.1007/s00464-008-0202-8

    Article  PubMed  Google Scholar 

  9. Trastulli S, Farinella E, Cirocchi R, Cavaliere D, Avenia N, Sciannameo F, Gulla N, Noya G, Boselli C (2012) Robotic resection compared with laparoscopic rectal resection for cancer: systematic review and meta-analysis of short-term outcome. Colorectal Dis 14(4):e134–e156. https://doi.org/10.1111/j.1463-1318.2011.02907.x

    Article  CAS  PubMed  Google Scholar 

  10. Ahmed J, Cao H, Panteleimonitis S, Khan J, Parvaiz A (2017) Robotic versus laparoscopic rectal surgery in high-risk patients. Colorectal Dis. https://doi.org/10.1111/codi.13783

    Article  PubMed  Google Scholar 

  11. Xiong B, Ma L, Huang W, Zhao Q, Cheng Y, Liu J (2015) Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of eight studies. J Gastrointest Surg 19(3):516–526. https://doi.org/10.1007/s11605-014-2697-8

    Article  PubMed  Google Scholar 

  12. Jayne D, Pigazzi A, Marshall H, Croft J, Corrigan N, Copeland J, Quirke P, West N, Rautio T, Thomassen N, Tilney H, Gudgeon M, Bianchi PP, Edlin R, Hulme C, Brown J (2017) Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR randomized clinical trial. JAMA 318(16):1569–1580. https://doi.org/10.1001/jama.2017.7219

    Article  PubMed  PubMed Central  Google Scholar 

  13. Foo CC, Law WL (2016) The learning curve of robotic-assisted low rectal resection of a novice rectal surgeon. World J Surg 40(2):456–462. https://doi.org/10.1007/s00268-015-3251-x

    Article  PubMed  Google Scholar 

  14. Son GM, Kim JG, Lee JC, Suh YJ, Cho HM, Lee YS, Lee IK, Chun CS (2010) Multidimensional analysis of the learning curve for laparoscopic rectal cancer surgery. J Laparoendosc Adv Surg Tech A 20(7):609–617. https://doi.org/10.1089/lap.2010.0007

    Article  PubMed  Google Scholar 

  15. deSouza AL, Prasad LM, Ricci J, Park JJ, Marecik SJ, Zimmern A, Blumetti J, Abcarian H (2011) A comparison of open and robotic total mesorectal excision for rectal adenocarcinoma. Dis Colon Rectum 54(3):275–282. https://doi.org/10.1007/DCR.0b013e3182060152

    Article  PubMed  Google Scholar 

  16. Baek JH, McKenzie S, Garcia-Aguilar J, Pigazzi A (2010) Oncologic outcomes of robotic-assisted total mesorectal excision for the treatment of rectal cancer. Ann Surg 251(5):882–886. https://doi.org/10.1097/SLA.0b013e3181c79114

    Article  PubMed  Google Scholar 

  17. Baik SH, Gincherman M, Mutch MG, Birnbaum EH, Fleshman JW (2011) Laparoscopic vs open resection for patients with rectal cancer: comparison of perioperative outcomes and long-term survival. Dis Colon Rectum 54(1):6–14. https://doi.org/10.1007/DCR.0b013e3181fd19d0

    Article  PubMed  Google Scholar 

  18. Choi DJ, Kim SH, Lee PJ, Kim J, Woo SU (2009) Single-stage totally robotic dissection for rectal cancer surgery: technique and short-term outcome in 50 consecutive patients. Dis Colon Rectum 52(11):1824–1830. https://doi.org/10.1007/DCR.0b013e3181b13536

    Article  PubMed  Google Scholar 

  19. Hellan M, Anderson C, Ellenhorn JD, Paz B, Pigazzi A (2007) Short-term outcomes after robotic-assisted total mesorectal excision for rectal cancer. Ann Surg Oncol 14(11):3168–3173. https://doi.org/10.1245/s10434-007-9544-z

    Article  PubMed  Google Scholar 

  20. Nagtegaal ID, VandeVelde CJ, VanderWorp E, Kapiteijn E, Quirke P, VanKrieken JH, Cooperative Clinical Investigators of the Dutch Colorectal Cancer G (2002) Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control. J Clin Oncol 20(7):1729–1734. https://doi.org/10.1200/jco.2002.07.010

    Article  PubMed  Google Scholar 

  21. Alfieri S, Di Miceli D, Menghi R, Cina C, Fiorillo C, Prioli F, Rosa F, Doglietto GB, Quero G (2018) Single-docking full robotic surgery for rectal cancer: a single-center experience. Surg Innov 1:5. https://doi.org/10.1177/1553350618765868

    Article  Google Scholar 

  22. Alfieri S, Quero G, Parvaiz A (2018) Robotic-assisted vs conventional laparoscopic surgery for rectal cancer. JAMA 319(11):1163–1164. https://doi.org/10.1001/jama.2017.21692

    Article  PubMed  Google Scholar 

  23. Toda S, Kuroyanagi H (2014) Laparoscopic surgery for rectal cancer: current status and future perspective. Asian J Endosc Surg 7(1):2–10. https://doi.org/10.1111/ases.12074

    Article  PubMed  Google Scholar 

  24. Fung AK, Aly EH (2013) Robotic colonic surgery: is it advisable to commence a new learning curve? Dis Colon Rectum 56(6):786–796. https://doi.org/10.1097/DCR.0b013e318285b810

    Article  PubMed  Google Scholar 

  25. Martínez-Pérez A, Carra MC, Brunetti F, de’Angelis N (2017) Short-term clinical outcomes of laparoscopic vs open rectal excision for rectal cancer: a systematic review and meta-analysis. World J Gastroenterol 23(44):7906

    Article  PubMed  PubMed Central  Google Scholar 

  26. Saber AA, Meslemani AM, Davis R, Pimentel R (2004) Safety zones for anterior abdominal wall entry during laparoscopy: a CT scan mapping of epigastric vessels. Ann Surg 239(2):182

    Article  PubMed  PubMed Central  Google Scholar 

  27. de Rosnay P, Chandiramani M, Usman S, Owen E (2011) Injury of epigastric vessels at laparoscopy: diagnosis and management. Gynecol Surg 8(3):353–356

    Article  Google Scholar 

  28. Rahn DD, Phelan JN, Roshanravan SM, White AB, Corton MM (2010) Anterior abdominal wall nerve and vessel anatomy: clinical implications for gynecologic surgery. Am J Obstet Gynecol 202(3):234.e231–234.e235

    Article  Google Scholar 

  29. Zimmern A, Prasad L, Marecik S, Park J, Abcarian H (2010) Robotic colon and rectal surgery: a series of 131 cases. World J Surg 34(8):1954–1958

    Article  PubMed  Google Scholar 

  30. Ursi P, Santoro A, Gemini A, Arezzo A, Pironi D, Renzi C, Cirocchi R, Di Matteo F, Maturo A, D’Andrea V (2018) Comparison of outcomes following intersphincteric resection vs low anterior resection for low rectal cancer: a systematic review. G Chir 39(3):123

    CAS  PubMed  Google Scholar 

  31. Popescu I, Vasilescu C, Tomulescu V, Vasile S, Sgarbura O (2010) The minimally invasive approach, laparoscopic and robotic, in rectal resection for cancer. A single center experience. Acta Chir Iugosl 57(3):29–35

    Article  CAS  PubMed  Google Scholar 

  32. Allemann P, Duvoisin C, Di Mare L, Hubner M, Demartines N, Hahnloser D (2016) Robotic-assisted surgery improves the quality of total mesorectal excision for rectal cancer compared to laparoscopy: results of a case-controlled analysis. World J Surg 40(4):1010–1016. https://doi.org/10.1007/s00268-015-3303-2

    Article  PubMed  Google Scholar 

  33. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM, group MCt (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365(9472):1718–1726. https://doi.org/10.1016/S0140-6736(05)66545-2

    Article  PubMed  Google Scholar 

  34. Laurent C, Leblanc F, Wutrich P, Scheffler M, Rullier E (2009) Laparoscopic versus open surgery for rectal cancer: long-term oncologic results. Ann Surg 250(1):54–61. https://doi.org/10.1097/SLA.0b013e3181ad6511

    Article  PubMed  Google Scholar 

  35. Strohlein MA, Grutzner KU, Jauch KW, Heiss MM (2008) Comparison of laparoscopic vs. open access surgery in patients with rectal cancer: a prospective analysis. Dis Colon Rectum 51(4):385–391. https://doi.org/10.1007/s10350-007-9178-z

    Article  PubMed  Google Scholar 

  36. Tsang WW, Chung CC, Kwok SY, Li MK (2006) Laparoscopic sphincter-preserving total mesorectal excision with colonic J-pouch reconstruction: five-year results. Ann Surg 243(3):353–358. https://doi.org/10.1097/01.sla.0000202180.16723.03

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Awwad GE, Tou SI, Rieger NA (2013) Prognostic significance of lymph node yield after long-course preoperative radiotherapy in patients with rectal cancer: a systematic review. Colorectal Dis 15(4):394–403. https://doi.org/10.1111/codi.12011

    Article  CAS  PubMed  Google Scholar 

  38. Baik SH, Kwon HY, Kim JS, Hur H, Sohn SK, Cho CH, Kim H (2009) Robotic versus laparoscopic low anterior resection of rectal cancer: short-term outcome of a prospective comparative study. Ann Surg Oncol 16(6):1480–1487. https://doi.org/10.1245/s10434-009-0435-3

    Article  PubMed  Google Scholar 

  39. Hida K, Okamura R, Sakai Y, Konishi T, Akagi T, Yamaguchi T, Akiyoshi T, Fukuda M, Yamamoto S, Yamamoto M, Nishigori T, Kawada K, Hasegawa S, Morita S, Watanabe M, Japan Society of Laparoscopic Colorectal S (2017) Open versus laparoscopic surgery for advanced low rectal cancer: a large, multicenter, propensity score matched cohort study in Japan. Ann Surg. https://doi.org/10.1097/sla.0000000000002329

    Article  Google Scholar 

  40. Prete FP, Pezzolla A, Prete F, Testini M, Marzaioli R, Patriti A, Jimenez-Rodriguez RM, Gurrado A, Strippoli GFM (2017) Robotic versus laparoscopic minimally invasive surgery for rectal cancer: a systematic review and meta-analysis of randomized controlled trials. Ann Surg. https://doi.org/10.1097/sla.0000000000002523

    Article  Google Scholar 

  41. Jeong SY, Park JW, Nam BH, Kim S, Kang SB, Lim SB, Choi HS, Kim DW, Chang HJ, Kim DY, Jung KH, Kim TY, Kang GH, Chie EK, Kim SY, Sohn DK, Kim DH, Kim JS, Lee HS, Kim JH, Oh JH (2014) Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 15(7):767–774. https://doi.org/10.1016/S1470-2045(14)70205-0

    Article  Google Scholar 

  42. Baik SH, Kim NK, Lim DR, Hur H, Min BS, Lee KY (2013) Oncologic outcomes and perioperative clinicopathologic results after robot-assisted tumor-specific mesorectal excision for rectal cancer. Ann Surg Oncol 20(8):2625–2632. https://doi.org/10.1245/s10434-013-2895-8

    Article  PubMed  Google Scholar 

  43. Pai A, Marecik SJ, Park JJ, Melich G, Sulo S, Prasad LM (2015) Oncologic and clinicopathologic outcomes of robot-assisted total mesorectal excision for rectal cancer. Dis Colon Rectum 58(7):659–667. https://doi.org/10.1097/DCR.0000000000000385

    Article  PubMed  Google Scholar 

  44. Pigazzi A, Luca F, Patriti A, Valvo M, Ceccarelli G, Casciola L, Biffi R, Garcia-Aguilar J, Baek JH (2010) Multicentric study on robotic tumor-specific mesorectal excision for the treatment of rectal cancer. Ann Surg Oncol 17(6):1614–1620. https://doi.org/10.1245/s10434-010-0909-3

    Article  PubMed  Google Scholar 

  45. Baek S-J, Kim S-H, Cho J-S, Shin J-W, Kim J (2012) Robotic versus conventional laparoscopic surgery for rectal cancer: a cost analysis from a single institute in Korea. World J Surg 36(11):2722–2729

    Article  PubMed  Google Scholar 

  46. Bertani E, Chiappa A, Biffi R, Bianchi P, Radice D, Branchi V, Cenderelli E, Vetrano I, Cenciarelli S, Andreoni B (2011) Assessing appropriateness and quality-of-life short-term outcomes employing different treatment approaches. Int J Colorectal Dis 26:1317–1327

    Article  PubMed  Google Scholar 

  47. Morelli L, Guadagni S, Lorenzoni V, Di Franco G, Cobuccio L, Palmeri M, Caprili G, D’Isidoro C, Moglia A, Ferrari V (2016) Robot-assisted versus laparoscopic rectal resection for cancer in a single surgeon’s experience: a cost analysis covering the initial 50 robotic cases with the da Vinci Si. Int J Colorectal Dis 31(9):1639–1648

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Ms. Marion Merck, Mr. Guy Temporal, and Mr. Christopher Burel for their assistance in proofreading the manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author information

Affiliations

  1. Digestive Surgery Unit of the Fondazione Policlinico “A.Gemelli”, Catholic University of Sacred Heart, Largo Agostino Gemelli 8, 00166, Rome, Italy

    Giuseppe Quero, Fausto Rosa, Claudio Fiorillo, Caterina Cina, Roberta Menghi, Giovanni B. Doglietto & Sergio Alfieri

  2. Department of Pathology of the Fondazione Policlinico “A.Gemelli”, Catholic University of Sacred Heart, Largo Agostino Gemelli 8, 00166, Rome, Italy

    Riccardo Ricci & Maria C. Giustiniani

Authors
  1. Giuseppe Quero
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Fausto Rosa
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Riccardo Ricci
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Claudio Fiorillo
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Maria C. Giustiniani
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Caterina Cina
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Roberta Menghi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Giovanni B. Doglietto
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Sergio Alfieri
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Giuseppe Quero.

Ethics declarations

Conflict of interest

Giuseppe Quero, Fausto Rosa, Riccardo Ricci, Claudio Fiorillo, Maria Cristina Giustiniani, Caterina Cina, Roberta Menghi, Giovanni Battista Doglietto, Sergio Alfieri declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study formal consent is not required.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Quero, G., Rosa, F., Ricci, R. et al. Open versus minimally invasive surgery for rectal cancer: a single-center cohort study on 237 consecutive patients. Updates Surg 71, 493–504 (2019). https://doi.org/10.1007/s13304-019-00642-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13304-019-00642-3

Keywords

  • Rectal cancer
  • Minimally invasive
  • Robotic proctectomy
  • Laparoscopy