Topic: A Bespoke Approach to Rectal Cancer Resection and Management

The platform or mode of resecting colorectal cancer, particularly in the rectum can influence outcome – it is not just the expertise of the primary surgeon, but also the mode of resection (open vs. laparoscopic/ robotic) that will predict not only the length of stay due to recovery but also the pathological parameters; enhanced recovery programmes further accelerate patient discharge. There are very important team factors too; the skill of assistance is magnified in laparoscopic colorectal resection where not only the camera operator needs to understand and predict steps to smooth the operation, but also a second assistant particularly in left-sided resection can retract during the case thus facilitating easier dissection. However, for rectal cancer resection, recent trials using a non-inferiority assessment for oncological parameters have shown that patients undergoing a laparoscopic resection fared worse than those undergoing open surgery. The robotic platform for rectal cancer allows a very detailed evaluation of pelvic anatomy due to its 3D visualisation – in addition the wrist element afforded by the robot enables excellent dissection of the TME plane, akin to the early descriptions popularised by Heald et al. but with a more magnified view. It is within the confines of the pelvis that robotic resection is likely to be of greatest benefit, particularly for dissection of the mid and low rectum – the extra robotic arm can be continuously placed in a similar fashion to a St Mark's pelvic retractor in open surgery thus enabling accurate retraction without assistance fatigue or movement as may occur in open or standard laparoscopic surgery. This should both reduce conversion to open resection for low rectal cancer and improve oncological parameters, either equivalent to, or superior to those of open resection. Lower conversion rates should enhance earlier discharge and hospital recovery and reduce costs in the longer term. Whilst some parts of the world have high rates of uptake for laparoscopic colorectal resection, others lag far behind – the use of robotic surgery currently represents a small minority of cases; going forward a tailored approach to colorectal cancer resection needs to encompass and study these important factors to achieve the best clinical and oncological outcomes for patients. In addition other modalities including transanal total mesorectal excision (TaTME) to enable the inferior aspect of TME dissection and its place also need detailed evaluation.
The evolution of therapies in rectal cancer continues to expand allowing a unique approach through local excision, chemoradio - and contact therapy, watch and wait along with endoscopic and extended resection. This Special Issue aims to focus on the breadth of options available to clinicians and patients in this area.

Rectal, cancer, robotic, multidisciplinary, teamwork, image guided

31 Jul 2018