Minimally invasive total mesorectal excision: assessing the surgical treatment of rectal carcinoma

The treatment of rectal carcinoma consists of (chemo)radiotherapy and the surgical resection of the tumor, including its surrounding fat tissue and lymph nodes: total mesorectal excision (TME). The surgical resection has evolved significantly over the last twenty years: Initially, open abdominal surgery was necessary, but after the introduction of the laparoscopic technique, this has become the standard (laparoscopic TME). Subsequently, robot-assisted abdominal surgery (robot-assisted TME), and transanal excision of the tumor (TaTME) were introduced. This thesis aims to compare outcomes between the following three minimally invasive techniques for the surgical resection of rectal carcinoma: laparoscopic TME (L-TME), robot-assisted TME (R-TME) and transanal TME (TaTME).
The initial period (learning curve) of the minimally invasive technique was not found to be associated with an increase in complications or survival. However, an increase in complications and local recurrence has been found in papers reporting on L-TME and TaTME during the learning curve. This could be due to the technological advances of the robot-assisted technique, or because L-TME and TaTME differ significantly from the preceding resection technique, while R-TME is quite similar to the preceding resection technique.
After the learning curve has been reached, outcomes do not differ significantly regarding complications and survival. However, L-TME is found to be associated with an increase in stoma construction, and an increase in periprocedural changes of the operative plan in low rectal tumors. TaTME and R-TME might therefore be a better technique for the excision of technically difficult low rectal tumors. More research should aim to elucidate whether a reduction in stoma construction in the R-TME and TaTME leads to an increase in quality of life, and whether the additional costs of these techniques outweigh the potential gain in quality of life.