Laparoscopic TME in rectal cancer--electronic supplementary: op-video.
BACKGROUND
Laparoscopic total mesorectal excision (TME) for rectal cancer has been proved in various studies. The minimal invasive procedure is feasible and safe which was demonstrated in many studies. However, the results of prospective, randomized studies providing valuable evidence are still not available. Compared to conventional surgery, the laparoscopic technique has short-term advantages including less pain, shorter duration of postoperative ileus, less fatigue, better pulmonary function, and less blood loss (Leung et al., Lancet 363:1187-1192, 2004; Braga et al., Dis Colon Rectum 48:217-223, 2005; Jayne et al., J Clin Oncol 25:3061-3068, 2007; Agha et al., Surg Endosc 22:2229-2237, 2008).


METHODS
The autonomic nerve sparing TME technique is the gold standard in rectal cancer resection even in conventional or laparoscopic procedure. With regard of the oncological dimension, the laparoscopic TME technique is not different compared to the open procedure. However, a standardized laparoscopic step-by-step procedure may simplify the operation and can reduce operation time.


RESULTS
There are no studies available which compare different types of TME procedures. Most surgeons start the operation left laterally mobilizing the sigmoid colon first. In the laparoscopic technique, we recommend the medial to lateral approach starting the operation at the right side of the rectum and sigmoid colon. A nerve sparing TME technique can be performed easier, and the identification of the left ureter may be simplified. After multiple workshops and extensive discussion with national and international experts, we developed a standardized laparoscopic "10 step TME procedure." Reviewing the results of laparoscopic TME the studies do not allow firm conclusions as to the questions of whether the safety and efficacy of laparoscopic TME is equal or superior to open TME (Breukink et al. 2006). Actually, we are waiting for large prospective randomized studies comparing laparoscopic TME with the traditional open procedure (Bonjer et al., Dan Med Bull 56:89-91, 2009).


CONCLUSIONS
Laparoscopic TME appears to have clinically measurable short-term advantages in patients with primary resectable rectal cancer based on evidence mainly from nonrandomized studies (Breukink et al. 5). In nearly all published studies, the efficacy and technical feasibility of laparoscopic surgery for rectal cancer could be demonstrated regarding perioperative morbidity and oncological outcome. A standardized laparoscopic TME technique can be strongly recommended.
Fürst
Alois
A
Department of Surgery and Minimal Invasive Surgery, Caritas-Clinic St. Josef, Landshuterstr. 65, 93053 Regensburg, Germany. afuerst@caritasstjosef.de
Schwandner
Oliver
O
Heiligensetzer
Arthur
A
Iesalnieks
Igors
I
Agha
Ayman
A
D017776:Autonomic Pathways / Q000033:anatomy & histology; D002985:Clinical Protocols; D004210:Dissection / Q000379:methods; D005240:Feasibility Studies; D006801:Humans; D056888:Patient Positioning / Q000379:methods; D011351:Proctoscopy / Q000379:methods*; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000601:surgery*; D012189:Retrospective Studies; D012449:Safety; D013997:Time Factors; D016896:Treatment Outcome; D014513:Ureter / Q000033:anatomy & histology