This article reviews the current evidence for laparoscopic surgery in treating colorectal cancers. It discusses several large randomized controlled trials that compared short-term and long-term outcomes of laparoscopic versus open surgery. The trials found no significant differences in cancer recurrence rates, survival rates, or number of lymph nodes retrieved between the two surgical methods. Meta-analyses of the trials validated that laparoscopic surgery is as safe and effective as open surgery for treating colorectal cancer. While the laparoscopic approach has benefits like less blood loss and shorter hospital stays, long-term oncologic outcomes are comparable to open surgery.

1. Current evidence for laparoscopic
surgery in colorectal cancers

2. Review Article
Current evidence for laparoscopic surgery in
colorectal cancers
Laletendu Mahapatra a
, Amanjeet Singh b,
*
a
Associate Consultant, Department of GI Surgery, GI Oncology and Minimal Access Surgery, Medanta – The Medicity,
Gurgaon, India
b
Senior Consultant, Department of GI Surgery, GI Oncology and Minimal Access Surgery, Medanta – The Medicity,
Gurgaon, India
1. Introduction
The incidence of colorectal cancer globally is around one
million every year, and is the second most common cancer in
women and third most common cancer in men.1
About 80–90%
of patients with cancer of colon and rectum are treated
surgically. As with other cancers, minimally invasive techni-
ques are increasingly being used for colorectal surgeries. The
safety and benefits of these techniques in colorectal surgery
have already been established, but there are still important
issues including long-term oncological outcome for advanced
colon cancer, cost effectiveness, and the impact on quality of
life of patients. The aim of this paper is to review the current
status of laparoscopic colorectal surgery, recommendation of
technique, and evidences for short- and long-term outcomes.
2. Laparoscopic colorectal surgery
Since the first sigmoid resection by laparoscopic method by
Jacobs in 1991, indications, technique, standardization, pre
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x
a r t i c l e i n f o
Article history:
Received 17 July 2015
Accepted 28 July 2015
Available online xxx
Keywords:
Laparoscopic colorectal surgery
CLASICC
COLOR
Barcelona study
Meta-analysis
a b s t r a c t
The article lays an emphasis on the laparoscopic surgical method used to treat colorectal
cancer. It reviews the current status of the laparoscopic colorectal surgeries and recom-
mendation of evidences for short- and long-term outcome. The early results were against
laparoscopic approach. There was a need of properly designed study to validate or invalidate
these findings. Seven large-scale trials compared laparoscopic and open colectomy for colon
carcinoma and examined short-term and long-term outcomes. These trials included the
Clinical Outcomes of Surgical Therapies (COST) trial funded by the National Cancer Institute
in the United States, the Conventional versus Laparoscopic-Assisted Surgery in Colorectal
Cancer (CLASICC) trial in the United Kingdom, the Colon Cancer Laparoscopic or Open
Resection (COLOR), a multicenter European trial.
For the validation of the argument that laparoscopy is safe, meta-analysis was per-
formed. Certain conclusions of meta-analysis are also presented in this article. The indi-
vidual merits and weaknesses of laparoscopic surgery as compared with open surgery as the
primary treatment of colorectal cancer are being highlighted in this article.
# 2015 Published by Elsevier B.V. on behalf of Indraprastha Medical Corporation Ltd.
* Corresponding author. Tel.: +91 9999150511.
E-mail address: dramanarora03@yahoo.com (A. Singh).
APME-312; No. of Pages 7
Please cite this article in press as: Mahapatra L, Singh A. Current evidence for laparoscopic surgery in colorectal cancers, Apollo Med.
(2015), http://dx.doi.org/10.1016/j.apme.2015.07.016
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
http://dx.doi.org/10.1016/j.apme.2015.07.016
0976-0016/# 2015 Published by Elsevier B.V. on behalf of Indraprastha Medical Corporation Ltd.

3. and postoperative management have been changing and
constantly evolving.2
Initial studies of laparoscopic colorectal
surgery for benign colorectal disease had shown high rate of
complications (18%), including inadvertent enterotomies,
hemorrhage, anastomotic leaks, and pelvic abscesses. Simi-
larly, in laparoscopic colorectal surgery for malignant indica-
tion, studies have shown trocar site recurrences, including one
case series documenting a 21% rate3
compared to 1% in open
technique. Another study showed decreased survival at 2
years of 76% from 87% for all stages ( p = 0.02) of colorectal
cancer collected from a prospective database of 377 consecu-
tive laparoscopic patients. Chan et al. showed an increased
local recurrence rate at 3-year follow-up of 9.8% in the
laparoscopically converted group as compared to 2.8% in open
patients ( p = 0.03).
As most of the early results were against laparoscopic
approach, there was a need of properly designed study to
validate or invalidate these findings. Seven large-scale trials
compared laparoscopic and open colectomy for colon carcino-
ma and examined short-term and long-term outcomes. These
trials included the Clinical Outcomes of Surgical Therapies
(COST) trial funded by the National Cancer Institute in the
United States, the Conventional versus Laparoscopic-Assisted
Surgery in Colorectal Cancer (CLASICC) trial in the United
Kingdom, the Colon Cancer Laparoscopic or Open Resection
(COLOR), a multicenter European trial, the Barcelona trial, and
several others.4–6,15,34–39
The main focus of these trials was
oncologic outcomes, but short-term outcomes, quality of life,
and safety were also evaluated. The CLASICC trial was the only
large trial that also evaluated MIS in rectal cancer.
3. Current status
3.1. Evidence for colon cancer
3.1.1. COST study group
This trial included 863 patients among 48 centers in the United
States and Canada. Patients who underwent colorectal
resection, excluding that of transverse colon and rectum,
between 1994 and 2001 were included. The endpoint was
tumor recurrence.6
The first results were published in 2002
showing benefits of laparoscopy approach as improved quality
of life, significantly shorter hospital stay, and requirement of
less analgesia compared to the open group (5 versus 6 days,
p < 0.001) in the early postoperative period. The conversion
rate to open resection was 21%, and remained consistent
throughout the study course.
Recently published 5-year outcomes data from the COST
group trial, which followed 852 patients randomly assigned to
either laparoscopic or open colorectal resections for cancer,
showed an overall survival of 74.6% with laparoscopic
resection versus 76.4% with open surgery ( p = 0.93).7
Dis-
ease-free survival was 68.4% and 69.2% ( p = 0.94), respectively.
Local recurrence rates were 2.6% and 2.3% ( p = 0.79), and
overall rates of recurrence were 21.8% and 19.4% ( p = 0.25),
respectively.7
There was no significant difference in hepatic
and pulmonary metastases between the groups in this study.
The COST study's 5-year follow-up data also did not show a
significantly higher wound-site or laparoscopic port-site
recurrence when compared with open surgery.7
The rate
was 0.5% following laparoscopic surgery and 0.9% following
open surgery ( p = 0.43).
3.1.2. COLOR9
Around 1076 patients were included from 29 European centers
between 1997 and 2003. Similar to COST, the exclusion criteria
include tumor of transverse colon, extra-peritoneal rectal
cancer, and patients with BMI more than 30%. The primary
endpoint was cancer-free survival at 3 years. Surgeons who
had performed at least 20 laparoscopic colostomies were
included in the trial. The rate of conversion was 17% compared
to 21% in COST. The reason behind the conversion was due to
either bulky disease or fixity to pelvic wall but may be the
result of inadequate preoperative imaging, and only 5% of
patients underwent CT as preoperative imaging modality. If
we analyze the short-term outcome that was published in
2005, although the duration (lap: 145 min, open: 115 min;
p < 0.0001) for laparoscopic surgery was longer compared to
open technique (may be because of learning curve), the blood
loss was less (lap: 100 cc, open: 175 cc; p < 0.0001). There were
no significant differences in oncologic outcomes, including the
rate of positive margins ( p = 1.0), in the number of lymph
nodes harvested ( p = 0.35). Postoperative morbidity, pulmo-
nary or cardiac events, and anastomotic failures or wound
infections were similar.8
At 3 years, recurrences rates both
local and distant were similar between both groups. Overall
and cancer-free survival was not significantly different,
regardless of disease stage. The 3-year cancer-free survival
for all stages was 72.4% in the laparoscopic group and 76.4% in
the open group ( p = 0.7). Overall survival at 3 years for all
stages was 81.8% in the laparoscopic group and 84.2% in the
open group ( p = 0.45).9
3.1.3. CLASICC
The study was performed in United Kingdom where 794
patients were included from 27 centers between 1996 and 2002.
This was the first study, which included rectal cancer patients
unlike COST or COLOR where they were excluded. Patients
were randomized in a 2:1 basis, such that 526 were in the
laparoscopic group and 268 in the open group. Of the 794
patients, 413 (52%) had colon cancer. The short-term primary
endpoints were rates of positive circumferential and longitu-
dinal resection margins, proportion of Dukes' C2 tumors, and
in-hospital mortality. Long-term endpoints were survival,
recurrence, and quality of life at 3 and 5 years, of which results
are now available.
In 2005, the short-term results were published, showing no
significant differences in the number of lymph nodes retrieval
or the number of positive margins for colon cancer. The rate of
conversion for colon cancer was 25% and for rectal cancer was
34%.Themostcommoncauseforconversioninbothgroupswas
fixation of the tumor or inaccessible laparoscopically as in 20%
of low rectal cancers. Intraoperative complications, including
intraoperative hemorrhage or arrhythmia ( p = 0.002) and death
rates (open versus laparoscopic 9% versus 5% and 1%,
respectively; p = 0.34), were higher in converted groups. These
in turn contributed to the low overall survival in converted
groups. However, there was no significant difference in the rate
of distant recurrence in converted cases.10
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x2
APME-312; No. of Pages 7
Please cite this article in press as: Mahapatra L, Singh A. Current evidence for laparoscopic surgery in colorectal cancers, Apollo Med.
(2015), http://dx.doi.org/10.1016/j.apme.2015.07.016

4. The long-term results (5 years) showed no statistically
significant difference in overall survival (lap: 57.9%, open:
58.1%; p = 0.848). Patient with colon cancer had similar overall
survival (lap: 55.7%, open: 62.7%, p = 0.253) and cancer-free
survival (lap: 57.6%, open: 64.0%, p = 0.399).10
In total, one
wound site recurrence was recorded in the open arm and nine
in the laparoscopic arm. There were no additional port-site
recurrences reported at 3 or 5 years.11,12
3.1.4. Barcelona Study
It was a single-center RCT from November 1993 to July 1998 in
Spain that included 219 patients with colon cancer greater
than 15 cm from the anal verge. The exclusion criteria were
cancers of transverse colon, patients with previous colonic
surgery, distant metastasis, obstructing tumors, and adjacent
organ invasion. The primary endpoint was cancer-related
survival with data analyzed according to the intention-to-treat
principle. The median follow-up period was 98 months.
Short-term analysis showed faster recovery and low
morbidity in patients undergoing laparoscopic approach.
Although statistically not significant, long-term results that
were published in 2008 showed favorable overall survival and
rate of recurrence for laparoscopic group.
Surprisingly, it had shown a higher probability of cancer-
related survival in the laparoscopic group, specifically those
with locally advanced disease. These results have not been
reproduced by other trials, however. The group postulates that
the surgical stress response is less in laparoscopy and
therefore may play a role in the reported oncologic advantage.
The underlining mechanism is attributed to less surgical
trauma, leading to less cytokine release and thus less tumor
stimulation. The role of vascular endothelial growth factor in
angiogenesis and tumor growth has been of particular interest,
as its levels are higher after open procedures.13,14
The main
drawback was that it was a single center study, and results
might not be reproducible in all centers.
3.2. Evidence for rectal cancer
Technically speaking, laparoscopic approach for rectal tumor
sounds more feasible as the visualization is better in depth and
better in the preservation of autonomic nerve plexuses with
reduced complication rate such as bladder and sexual
dysfunction. Although initial trials excluded patients with
rectal cancers due to anticipated technical difficulty, the
CLASICC study was the first to enroll rectal cancer patients in
randomized settings.
3.2.1. CLASICC trial
In the CLASICC study, 794 patients were enrolled for colon and
rectal cancers. Short-term analysis shows high positive
circumferential resection margins in those undergoing lapa-
roscopic LAR (lap: 12%, open: 6%, p = 0.19), which should have
increased the risk for local recurrence.11
However, on long-
term follow-up (3 and 5 years), we did not identify an increased
risk for local recurrence among patients having laparoscopic
operation for rectal cancer. Specifically, the 5-year local
recurrence rate for LAR was 9.4% for laparoscopy and 7.6%
for open ( p = 0.740). Overall, the distant recurrence rate was
20.9% (out of 111 cases) at 5 years (lap: 21%, open: 20.6%;
p = 0.820). Overall survival was also equivalent for laparoscopic
and open resection of rectal cancer (lap: 60.3%, open: 52.9%;
p = 0.132). Similar results were found regardless of whether
patients underwent LAR or APR (LAR – lap: 62.8%, open: 56.7%;
p = 0.247; APR – lap: 53.2%, open: 41.8%; p = 0.310). Cancer-free
survival at 5 years was also not significantly different for
patients with rectal cancer (lap: 53.2%, open: 52.1%; p = 0.953).
The 5-year cancer-free survival was not significantly different
for LAR (lap: 57.7%, open: 57.6%; p = 0.832) or for APR (lap: 41.4%,
open: 36.2%; p = 0.618).
3.2.2. COREAN Trial (open versus laparoscopic surgery for
mid or low rectal cancer after neoadjuvant
chemoradiotherapy)15
Between 2006 and 2009, patients with cT3N0-2 mid or low
rectal cancer without distant metastasis after preoperative
chemoradiotherapy were enrolled at three tertiary-referral
hospitals. Patients were randomized 1:1 to receive either open
surgery (n = 170) or laparoscopic surgery (n = 170), stratified
according to sex and preoperative chemotherapy regimen. The
total amount of morphine used was less in the laparoscopic
group than in the open group (median 107.2 mg [80.0–150.0]
versus 156.9 mg [117.0–185.2], p < 0.0001). Surgery time was
longer in the laparoscopic group (mean 244.9 min versus
197.0 min, p < 0.0001) but estimated blood loss was less in the
laparoscopic group than in the open group ( p = 0.006).
Involvement of the circumferential resection margin, macro-
scopic quality of the total mesorectal excision specimen,
number of harvested lymph nodes, and perioperative morbid-
ity did not differ between the two groups. The laparoscopic
surgery group showed earlier recovery of bowel function than
the open surgery group (time to pass first flatus, median 38.5 h
[23.0–53.0] versus 60.0 h [43.0–73.0], p < 0.0001; time to resume
a normal diet, 85.0 h [66.0–95.0] versus 93.0 h [86.0–121.0],
p < 0.0001; time to first defecation, 96.5 h [70.0–125.0] versus
123 h [94.0–156.0], p < 0.0001). In the postoperative period, 3
months after proctectomy or ileostomy takedown, the
laparoscopic group showed better physical functioning score,
less fatigue, and fewer micturition, gastrointestinal, and
defecation problems.
This was the first trial which included patients who had
undergone neoadjuvant chemoradiation for rectal cancers and
have shown that laparoscopic surgery in these patients does
not jeopardize short-term surgical outcomes such as CRM
positivity, macroscopic quality of the TME specimen, or the
number of harvested lymph nodes, which are associated with
long-term oncological outcomes, and does not increase
morbidity or mortality compared with open surgery. This trial
shows the safety of laparoscopic surgery when done by skilled
surgeons, despite the laparoscopic procedure being technically
more difficult for rectal cancer than for other cancers.
3.2.3. Other trials
A. COLOR II was non-inferiority RCT where 739 patients were
included. Inclusion criterion was single rectal mass within
15 cm from the anal verge on rigid proctoscopy or distal to
the conjugate line on CT/MRI. Patients with distant
metastasis, tumors amenable to local excision, and those
with radiographic features suggestive of local invasion
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 3
APME-312; No. of Pages 7
Please cite this article in press as: Mahapatra L, Singh A. Current evidence for laparoscopic surgery in colorectal cancers, Apollo Med.
(2015), http://dx.doi.org/10.1016/j.apme.2015.07.016

5. were excluded. The short-term results were published
which concluded that in selected patients with rectal
cancers treated by skilled surgeons, laparoscopic surgery
resulted in similar safety, resection margins, and com-
pleteness of resection compared to open surgery.16,17
B. Another study by Araujo et al. included 28 patients and
focused on laparoscopic versus open APR after neoadjuvant
therapy. Although no conversions were performed, the
interesting finding that this study found was significantly
fewer lymph nodes harvested in the laparoscopic group (5.5
nodes) compared to open (11.9) ( p = 0.04). They attributed
this difference to the small number of patients. However,
two local recurrences were noted in the open group and
none in the laparoscopic group [20] after 47 months of
follow-up.18
C. Zhou et al. included 171 patients, comparing open and
laparoscopic low and ultralow anterior resection. Patients
having tumor distal to the peritoneal reflection and 1.5 cm
above the dentate line were included. As shown by other
studies, the average operative time was not significantly
different (lap: 120 min, open: 106 min; p > 0.05), and blood
loss was significantly less with laparoscopy (lap: 20 ml,
open: 92 ml; p < 0.05). There was no significant difference in
days for starting of fluid ( p = 0.713) or in days of analgesia
( p = 0.225). However, bowel movement was significantly
early in the laparoscopic group (lap: 1.5 days, open: 2.7 days;
p = 0.009). Total hospital stay (lap: 8.1 days, open: 13.3 days;
p = 0.001) and postoperative complications such as urinary
retention, infection, obstruction, and anastomotic leakage
were significantly decreased with laparoscopy (lap: 6.1%,
open: 12.4%; p = 0.016). Two port site recurrences were
noted in the laparoscopic group and 3 pelvic local
recurrences in the open group. The authors conclude that
adequate resection of low rectal cancers can be performed
laparoscopically but is a technically challenging approach.
Long-term results regarding survival were not reported in
this study.19
D. Braga et al. published an article including 391 colorectal
cancers out of which 134 were rectal cancers. No difference
was found with respect to number of lymph nodes retrieved
or distal and radial margin involvement. The rate of
anastomotic leak was not significantly different (lap:
4.7%, open: 6.9%; p = 0.46) and reoperation was required
in 6.3% of laparoscopic compared to 9.4% of open cases. The
length of stay was significantly shorter for the laparoscopic
group (lap: 9.4 days, open: 12.7 days; p = 0.0001). Long-term
complications were also noted to be significantly lower in
the laparoscopic group. Five-year overall and disease-free
survival was not significantly different between open or
laparoscopic group. The local recurrence rate in rectal
cancer was 7.3% in the laparoscopic group and 8.8% in the
open group.20
E. The ACSOG Z6051 study published data of their phase II
pilot study in 2011 supporting that laparoscopic-assisted
resection had both acceptable oncologic and perioperative
clinical outcomes when compared to open resection. 54
patients with stage I to III rectal cancer obtained from 2001
to 2005 were included. Earlier return of bowel function was
also noted in the laparoscopic group ( p = 0.03) liken other
studies with no significant difference in the complication
rate (lap: 22.2%, open: 32.4%; p = 0.178). Local recurrence
was similar (lap: 2%, open: 4.2%, p = 0.417), as was 5-year
overall survival (lap: 90.8%, open: 88.5%; p = 0.261) and
disease-free survival (lap: 80.8%, open: 75.8%; p = 0.390).
4. Meta-analysis
In order to validate the argument that laparoscopy is a safe and
oncologically sound approach, several meta-analysis were
performed. We are presenting some of the conclusions of
meta-analysis. For better understanding, these analyses were
sub categorized as follows.
4.1. Postoperative recovery
A Cochrane review of 25 randomized controlled trials compar-
ing the short-term benefits of laparoscopic and open colorectal
resection surgery (for benign and malignant disease) has shown
significantly reduced intraoperative blood loss with laparoscop-
ic surgery than with open surgery, with a weighted mean
difference (WMD) of À71.8 cm3
(95% confidence interval [CI]
À113.0 to À30.8; p = 0.0006).21
Results from a meta-analysis of
the intensity of postoperative pain using a 0–100 visual analog
scale revealed that on day 1, the WMD between laparoscopic
and open groups was À9.3 (95% CI À13.2 to À5.4; p = 0001),
significantly favoring laparoscopy. At day 2, this difference was
no longer significant, but at day 3, patients who had undergone
laparoscopic surgery experienced significantly less pain
( p = 0.0002). The laparoscopic group also benefited from a
shorter duration of postoperative ileus and had significantly
improved postoperative pulmonary function (day 1 and 3 forced
vital capacity).22
These findings were confirmed by the meta-
analyses by Abraham and colleagues23
and by Reza and
colleagues24
focusing only on patients undergoing laparoscopic
or open resections for colorectal cancers. All three studies found
a significantly shorter length of hospital stay and reduced
incidence of wound infection with laparoscopic surgery than
with open surgery for colorectal cancer.
4.2. Postoperative mortality
The Cochrane review of 2394 participants from 17 trials
comparing laparoscopic with open colorectal resections found
no difference in mortality between laparoscopic (0.8%) and
conventional (1.1%) surgery (relative risk, 0.78; 95% CI À0.34 to
1.8; p = 0.55).21,25
More recently, a meta-analysis by Bonjer and
colleagues26
has reported mortality to be 1.6% for open surgery
versus 1.4% for laparoscopic surgery (odds ratio, 1.3; 95% CI 0.5–
3.4; p = 0.63).
4.3. Conversion rate
Review by Bonjer and colleagues26
in 2007 reported the
conversion rate of laparoscopic to open surgery as 19.0%.
Results from the CLASICC study have shown patient factors
that are important in conversion from laparoscopic to open
surgery to be larger body mass index, male sex, patients who
have rectal cancer, patients graded ASA grade III, and the
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x4
APME-312; No. of Pages 7
Please cite this article in press as: Mahapatra L, Singh A. Current evidence for laparoscopic surgery in colorectal cancers, Apollo Med.
(2015), http://dx.doi.org/10.1016/j.apme.2015.07.016

6. presence of greater local tumor spread.27
The last factor is not
surprising, because locally advanced cancers that involve
adjacent pelvic viscera through direct spread or local perfora-
tion would prove a more challenging en bloc resection for the
laparoscopic surgeon.
4.4. Oncologic safety
On meta-analysis of 1536 patients (796 undergoing laparo-
scopic surgery and 740 undergoing open surgery), Bonjer and
colleagues26
found the mean number of lymph nodes to be
11.8 Æ 7.4 in the laparoscopically resected specimens and 12.2
Æ 7.8 in the open colectomy specimens, a difference that was
not statistically different ( p = 0.40). They also found positive
resection margins in 2.1% of open colectomy specimens versus
1.3% of laparoscopic specimens, a difference that was not
significant (odds ratio, 1.8; 95% CI 0.7–4.5; p = 0.23). Similar
findings were published by Jackson and colleagues.28
4.5. Disease-free survival and recurrence
On meta-analysis of the four largest and best-established
randomized controlled trials, Bonjer and colleagues26
found 3-
year disease-free survival to be 75.3% with laparoscopic
resection versus 75.8% following open surgery (95% CI À5%
to 4%). Overall survival was reported as 83.5% and 82.2%,
respectively (95% CI À3% to 5%). By using Cox proportional
hazards, regression model analyses for disease-free survival
and overall survival stratified by trial, adjusting for sex, and
tumor stage found no difference between the treatments.
Another recent meta-analysis by Jackson and colleagues28
also
found no difference in cancer-related survival and disease
recurrence between the two groups. The COST study's 5-year
follow-up data also did not show a significantly higher wound-
site or laparoscopic port-site recurrence when compared with
open surgery.7
The rate was 0.5% following laparoscopic
surgery and 0.9% following open surgery ( p = 0.43), which,
along with the findings from the Barcelona Group and a meta-
analysis of seven studies with more than 18 months' follow-up
by Jackson and colleagues,28
shows that with experienced
surgeons, patients undergoing laparoscopic resections for
cancer are not at increased risk for recurrence.
4.6. Bladder and sexual dysfunction
Sexual dysfunction was shown to be higher (47%) compared to
open (5%) in terms of impotence and impaired ejaculation in
patients who had undergone laparoscopic APR as shown by
Quah and colleagues25
retrospectively in 40 patients, and
bladder dysfunction (evaluated by the incidence of urinary
retention) was not significantly different between the two
groups. Jayne and colleagues11
reported on sexual and bladder
dysfunction in a cohort of 147 patients randomly assigned to
undergo laparoscopic or open surgery for rectal cancer in the
CLASICC trial. They found that, although bladder function was
similar in the two groups, overall sexual function was worse in
men following laparoscopic surgery (a difference of 11.18; 95%
CI 22.99–0.63; p = 0.063). In particular, erectile function tended
to be worse in men who had undergone laparoscopic rectal
surgery (a difference of 5.84; 95% CI 10.94–0.74; p = 0.068). No
differences in female sexual function were detected in the two
groups. The study by Rezvani and colleagues29
retrospectively
compared eight patients who received preoperative chemor-
adiation therapy for rectal cancer with 52 patients who did not.
They found a trend toward a higher conversion rate to open
surgery and a significantly longer operative duration for
laparoscopic resections, which was also shown by the COREAN
trial. There were no changes in mortality or morbidity.
4.7. Cost effectiveness
A study by Braga and colleagues30
randomly assigned 517
patients undergoing colectomy to either laparoscopic or open
resection and compared hospital costs between the two
groups. Patients were followed up till 30 days after hospital
discharge to determine postoperative morbidity. This study
found that although the operative time was 37 min longer in
the laparoscopic group than in the open group, the overall
morbidity rate was significantly lower (18.2% versus 34.7%;
p = 0.0005), and the mean length of stay was shorter (9.9 days
versus 12.4 days; p = 0.0001). This study found that although
laparoscopic surgery has additional cost per patient, but this
cost was offset because of shorter hospital stay and the lower
cost of treating postoperative complications. The authors
found that the most expensive complications to treat were
infections (wound infection, abscesses, and sepsis), anasto-
motic leak, and intestinal obstruction.
4.8. Learning curve
Although a learning curve of 20 cases has been suggested, the
actual learning curve for laparoscopic surgery for colorectal
cancer probably is greater than 20 cases.31,32
It also has been
suggested that laparoscopic resection of the rectum is
technically more demanding and is associated with a longer
learning curve than other laparoscopic colonic resections.32
Conversion rates have been shown to decrease with increased
experience of surgeon. This variation is illustrated by the
conversion rate, which was as high as 34% in the recently
published multicenter CLASICC trial by Guillou and collea-
gues,11
the largest comparative randomized trial thus far
reporting specifically on a group of patients undergoing
laparoscopic surgery for rectal cancer. The inclusion criteria
for the large, randomized trials of laparoscopic colorectal
surgery such as COST or CLASICC require the operating
surgeon to have performed more than 20 laparoscopic
resections before submitting patients into the trial.
4.9. Single-incision laparoscopic resection
This is increasingly being used for cholecystectomy and more
recently for bariatric surgery. However, at present, there is not
enough data to suggest its safety and outcome. Only few case
series and case reports had been published. Papaconstantinou
and Thomas reported a case-matched comparison in 2011 of
SIL versus multiport laparoscopic colectomy for colon cancer
with 1-year outcomes. Between 2009 and 2010, 26 SIL colec-
tomy patients matched for factors including age, body mass
index, and American Society of Anesthesiologists score.33
Mean operative time was not significantly different at 144 min
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 5
APME-312; No. of Pages 7
Please cite this article in press as: Mahapatra L, Singh A. Current evidence for laparoscopic surgery in colorectal cancers, Apollo Med.
(2015), http://dx.doi.org/10.1016/j.apme.2015.07.016

7. ( p = 0.98). Total conversion rates were similar as well. The SIL
group had a 12% conversion rate (2 to multiport and 1 to a
hand-assisted port) and the multiport group had 15% conver-
sion rate (3 to hand-assisted port and 1 to open). There was no
difference noted regarding the number of lymph nodes
harvested (SIL: 18, multiport: 17; p = 0.88) or involvement of
proximal, distal, or radial margins ( p = 0.21). The length of stay
was noted to be shorter by 1.4 days in the SIL group, which was
significant ( p < 0.05). The mean follow-up was significantly
shorter for the SIL group at 13 months compared to multiport
at 21 months ( p < 0.001), since all the multiport cases predated
the SIL cases. At one year, there were no deaths or port-site
recurrences noted. Each group was found to have 8%
recurrence, all of which were distant metastasis in patients
with stage III disease. One-year survival was similar at 92% for
SIL and 92% for multiport ( p = 0.97).
5. Conclusions
This article highlights the individual merits and weaknesses of
laparoscopic as compared with open surgery as the primary
treatment of colorectal cancer. Several large RCTs support that
laparoscopic resection is not inferior to open resection of
colorectal cancer, likely due to technical principles that are
maintained during both open and laparoscopic operations.
The studies continue to support that an adequate oncologic
resection can be performed laparoscopically without
compromising outcomes. There is enough data showing the
safety of use of laparoscopy and short- and long-term outcomes
for colon cancers. With increasing use for laparoscopy in rectal
cancers, early studies have shown its safety and similar short-
termresults,althoughlong-termoutcomesforrectal cancersare
still awaited. While the use of SILS is appealing, its application
and outcomes must also be evaluated as rigorously as that of
laparoscopic resections for colon and rectal cancer before
widespread use can be encouraged.
Conflicts of interest
The authors have none to declare.
r e f e r e n c e s
1. American Cancer Society. Cancer Facts and Figures 2011.
Atlanta, GA: American Cancer Society; 2011.
2. Jacobs M, Verdeja JC, Goldstein HS. Minimally invasive colon
resection (laparoscopic colectomy). Surg Laparosc Endosc.
1991;1:144–150.
3. Berends FJ, Kazemier G, Bonjer HJ, Lange JF. Sub-cutaneous
metastases after laparoscopic colectomy. Lancet. 1994;344
(8914):58.
4. Lanthaler M, Biebl M, Mittermair R, et al. Intraoperative
colonoscopy for anastomosis assessment in
laparoscopically assisted left-sided colon resection: is it
worthwhile? J Laparoendosc Adv Surg Tech A. 2008;18(1):
27–31.
5. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for
perioperative care in elective colonic surgery: Enhanced
Recovery After Surgery (ERAS) Society recommendations.
Clin Nutr. 2012;31(6):783–800.
6. Clinical Outcomes of Surgical Therapy Study Group. A
comparison of laparoscopically assisted and open colectomy
for colon cancer. N Engl J Med. 2004;350(20):2050–2059.
7. Fleshman J, Sargent DJ, Green E, et al. Laparoscopic
colectomy for cancer is not inferior to open surgery based on
5-year data from the COST study group trial. Ann Surg.
2007;246(4):655–664.
8. Veldkamp R, Kuhry E, Hop WC, et al. Laparoscopic surgery
versus open surgery for colon cancer: short-term outcomes
of a randomized trial. Lancet Oncol. 2005;6(7):477–484.
9. Buunen M, Veldkamp R, Hop WC, et al. Colon Cancer
Laparoscopic or Open Resection Study Group, et al. Survival
after laparoscopic surgery versus open surgery for colon
cancer: long-term outcome of a randomized clinical trial.
Lancet Oncol. 2009;10(1):44–52.
10. Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of
conventional versus laparoscopic-assisted surgery in
patients with colorectal cancer (MRC CLASICC trial):
multicenter, randomized controlled trial. Lancet. 2005;365
(9472):1718–1726.
11. Jayne DG, Guillou PJ, Thorpe H, et al. Randomized trial of
laparoscopic-assisted resection of colorectal carcinoma: 3-
year results of the UK MRC CLASICC trial group. J Clin Oncol.
2007;25(21):3061–3068.
12. Jayne DG, Thorpe HC, Copeland J, Quirke P, Brown JM,
Guillou PJ. Five-year follow-up of the Medical Research
Council CLASICC trial of laparoscopically assisted versus
open surgery for colorectal cancer. Br J Surg. 2010;97
(11):1638–1645.
13. Lacy AM, Garcia-Valdecasa JC, Delgado S, et al. Laparoscopy-
assisted colectomy versus open colectomy for treatment of
non-metastatic colon cancer: a randomized trial. Lancet.
2002;359(9325):2224–2229.
14. Lacy AM, Delgado S, Castells A, et al. The long-term results
of a randomized clinical trial of laparoscopy-assisted versus
open surgery for colon cancer. Ann Surg. 2008;248(1):1–7.
15. Kang SB, Park JW, Jeong SY, et al. Open versus laparoscopic
surgery for mid or low rectal cancer after neoadjuvant
chemoradiotherapy (COREAN trial). Lancet Oncol. 2010;11
(7):637–645.
16. COLOR II Study GroupBuunen M, Bonjer HJ, et al. . COLOR II. A
randomized clinical trial comparing laparoscopic and open
surgery for rectal cancer. Dan Med Bull. 2009;56(2):89–91.
17. Baik SH, Gincherman M, Mutch MG, Birnbaum EH, Fleshman
JW. Laparoscopic vs open resection for patients with rectal
cancer: comparison of perioperative outcomes and long-
term survival. Dis Colon Rectum. 2011;54(1):6–14.
18. Araujo SE, Da Silva ESousa Jr AH, de Campos FG, et al.
Conventional approach  laparoscopic abdominoperineal
resection for rectal cancer treatment after neoadjuvant
chemoradiation: results of a prospective randomized trial.
Rev Hosp Clin Fac Med Sao Paulo. 2003;58(3):133–140.
19. Zhou ZG, Hu M, Lei WZ, et al. Laparoscopic versus open total
mesorectal excision with anal sphincter preservation for
low rectal cancer. Surg Endosc. 2004;18:1211–1215.
20. Braga M, Frasson M, Vignali A, Zuliani W, Civelli V, Di Carlo
V. Laparoscopic versus open colectomy in cancer patients:
long-term complications, quality of life, and survival. Dis
Colon Rectum. 2005;48:2217–2223.
21. Aziz O, Darzi AW. Laparoscopic resection for colorectal cancer:
evidence to date. Surg Oncol Clin N Am. 2008;17:519–531.
22. Schwenk W, Haase O, Neudecker J, et al. Short term benefits
for laparoscopic colorectal re-section. Cochrane Database Syst
Rev. 2005;3:CD003145.
23. Abraham NS, Young JM, Solomon MJ. Meta-analysis of
short-term outcomes after laparoscopic resection for
colorectal cancer. Br J Surg. 2004;91(9):1111–1124.
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x6
APME-312; No. of Pages 7
Please cite this article in press as: Mahapatra L, Singh A. Current evidence for laparoscopic surgery in colorectal cancers, Apollo Med.
(2015), http://dx.doi.org/10.1016/j.apme.2015.07.016

8. 24. Reza MM, Blasco JA, Andradas E, et al. Systematic review of
laparoscopic versus open surgery for colorectal cancer. Br J
Surg. 2006;93(8):921–928.
25. Quah HM, Jayne DG, Eu KW, et al. Bladder and sexual
dysfunction following laparoscopically assisted and
conventional open mesorectal resection for cancer. Br J Surg.
2002;89(12):1551–1556.
26. Bonjer HJ, Hop WCJ, Nelson H, et al. Laparoscopically
assisted vs open colectomy for colon cancer: a meta-
analysis. Arch Surg. 2007;142(3):298–303.
27. Thorpe H, Jayne DG, Guillou PJ, et al. Patient factors
influencing conversion from laparoscopically assisted to open
surgery for colorectal cancer. Br J Surg. 2008;95(2):199–205.
28. Jackson TD, Kaplan GG, Arena G, Page JH, Rogers SO.
Laparoscopic versus open resection for colorectal cancer: a
metaanalysis of oncologic outcomes. J Am Coll Surg. 2007;204
(3):439–446.
29. Rezvani M, Franko J, Fassler SA, et al. Outcomes in patients
treated by laparoscopic resection of rectal carcinoma after
neoadjuvant therapy for rectal cancer. JSLS. 2007;11(2):204–207.
30. Braga M, Frasson M, Vignali A, et al. Laparoscopic resection
in rectal cancer patients: out-come and cost-benefit
analysis. Dis Colon Rectum. 2007;50(4):464–471.
31. Bennett CL, Stryker SJ, Ferreira MR, et al. The learning curve
for laparoscopic colorectal surgery, Preliminary results from
a prospective analysis of 1194 laparoscopic-assisted
colectomies. Arch Surg. 1997;132(1):41–44.
32. Schlachta CM, Mamazza J, Seshadri PA, et al. Defining a
learning curve for laparoscopic colorectal resections. Dis
Colon Rectum. 2001;44(2):217–222.
33. Papaconstantinou HT, Thomas JS. Single-incision
laparoscopic colectomy for cancer: assessment of oncologic
resection and short-term outcomes in a case-matched
comparison with standard laparoscopy. Surgery. 2011;150
(4):820–827.
34. Hewett PJ, Allardyce RA, Bagshaw PF, et al. Short-term
outcomes of the Australasian randomized clinical study
comparing laparoscopic and conventional open surgical
treatments for colon cancer: the ALCCaS trial. Ann Surg.
2008;248(5):728–738.
35. Nelson H, Sargent DJ, Wieand HS, et al. A comparison of
laparoscopically assisted and open colectomy for colon
cancer. N Engl J Med. 2004;350(20):2050–2114.
36. Liang JT, Huang KC, Lai HS, Lee PH, Jeng YM. Oncologic
results of laparoscopic versus conventional open surgery for
stage II or III left-sided colon cancers: a randomized
controlled trial. Ann Surg Oncol. 2007;14(1):109–117.
37. Milsom JW, Böhm B, Hammerhofer KA, Fazio V, Steiger E,
Elson P. A prospective, randomized trial comparing
laparoscopic versus conventional techniques in colorectal
cancer surgery: a preliminary report. J Am Coll Surg. 1998;187
(1):46–57.
38. Heikkinen T, Msika S, Desvignes G, et al. Laparoscopic
surgery versus open surgery for colon cancer: short-term
out-comes of a randomized trial. Lancet Oncol. 2005;6(7):
477–484.
39. Lee JK, Delaney CP, Lipman JM. Current state of the art in
laparoscopic colorectal surgery for cancer: update on the
multi-centric international trials. Ann Surg Innov Res.
2012;6:5.
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 7
APME-312; No. of Pages 7
Please cite this article in press as: Mahapatra L, Singh A. Current evidence for laparoscopic surgery in colorectal cancers, Apollo Med.
(2015), http://dx.doi.org/10.1016/j.apme.2015.07.016

9. Apollo hospitals: http://www.apollohospitals.com/
Twitter: https://twitter.com/HospitalsApollo
Youtube: http://www.youtube.com/apollohospitalsindia
Facebook: http://www.facebook.com/TheApolloHospitals
Slideshare: http://www.slideshare.net/Apollo_Hospitals
Linkedin: http://www.linkedin.com/company/apollo-hospitals
Blog: http://www.letstalkhealth.in/