In 2004, the results of the Clinical Outcomes of Surgical Therapy (COST) trial were published in The New England Journal of Medicine. Eight hundred and seventy-two patients in 48 institutions were randomly assigned to open and laparoscopic approach for cancer. 3 years later, there were no difference in tumor recurrence (16 % LC vs. 18 % OC), wound recurrence (<1 % in both LC and OC), or overall survival (86 % LC vs. 85 % OC). The rates of intraoperative and overall complications were similar between the laparoscopic and open group, but perioperative recovery was faster in the laparoscopic surgery group. Another large randomized trial, the Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC), was conducted in the UK. The results of this study were published in 2007. Seven hundred and ninety-four patients in 27 UK medical centers were randomly assigned to laparoscopic (526) and open (268) approach for cancer, in a 2:1 fashion. 3 years later, there was no difference in OS (68.4 % LC vs. 66.7 % OC), DFS (66.3 % LC vs. 67.7 % OC), local recurrence, distant recurrence, or port site/wound recurrence. This trial again confirmed that in terms of recurrence and long-term survival, a laparoscopic approach for colon carcinoma is at least as good as the open approach. In addition, a subset of patients was used to demonstrate that OS, DFS, and local recurrence after laparoscopic rectal resection for rectal cancer were comparable with those of the open approach. The third largest randomized trial, the Colon cancer Laparoscopic or Open Resection (COLOR) trial in Europe, showed similar results, and several meta-analyses have been published from these data, confirming the results. Based on the outcomes of the COST study and other trials, the American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal Surgeons (SAGES) released the following statement: “Laparoscopic colectomy for curable cancer results in equivalent cancer-related survival to open colectomy when performed by experienced surgeons…” [9–11].

Technical difficulty also contributed to the slow adoption of the laparoscopic approach to colorectal cancer. Unlike other laparoscopic procedures such as Nissen fundoplication or cholecystectomy, laparoscopic colorectal resection requires multiple steps, including significant dissection in multiple abdominal quadrants, division of large vessels, removal of a specimen, and reanastomosis. There is a significant learning curve associated with laparoscopic colorectal surgery. It was recommended that a surgeon should have at least 20 laparoscopic colorectal resections to be considered sufficient and probably much more to be considered experienced. Fortunately, developments in video imaging, energy delivery, and stapling technology in the past decades have made it easier for more surgeons to adopt the laparoscopic technique. In addition, some have modified the technique. Surgeons have utilized the insertion of a handport into a small 7–9 cm incision to perform hand-assisted laparoscopic colorectal surgery. Proponents claim that this technique allows tactile and depth sensation and therefore shortens the learning curve. However, to date, there is no convincing evidence supporting clinical or training benefits of this technique over the standard laparoscopic approach.

While initial concerns about poor oncological outcomes associated with laparoscopic colon resection have been put to rest by the mountain of evidence presented, substantial data also demonstrated significant benefits associated with laparoscopic approach. Most of these studies have revealed that laparoscopic approach is linked with decreased hospital stay, less pain, less bleeding, earlier recovery of gastrointestinal function, shorter recovery, and a reduction in wound and other complication rates compared to the open approach [8, 9, 12–14]. Some meta-analyses also showed reduction in perioperative mortality [15].

A final concern with laparoscopic colectomy is that it may end up being much more expensive than open colectomy. This is particularly noted when length of hospital stay is not reduced or minimally reduced. Many single-center reports that have been published showing improvements or worsening of hospital costs. Most recently, some reports have suggested that in a multicenter approach the procedure can be completed with modest increase in costs of approximately $400 [14, 16–20].

Compared to segmental laparoscopic colon resection, laparoscopic rectal resection is technically more challenging. In the pelvis, manipulation of the bowel and its mesentery are limited by the narrow, long pelvis, particularly in males, tall patients, and in the obese. While avoiding injury to important structures such as the ureters, pelvic autonomic nerves, and the presacral veins, one must perform an oncologically sound total mesorectal excision. Despite these limitations, laparoscopic surgery can potentially enhance pelvic dissection in experienced hands by offering a view with higher magnification. In our opinion, using laparoscopic visualization, the correct anatomical planes can be identified and followed at least as well as in open surgery. Although this could potentially result in improved oncological outcomes and reduction in local recurrence rates, this is unlikely to ever be shown in randomized trials because of variability between patients, surgeons, and techniques, and the fact that the most difficult patients are likely to be performed open because of complicating factors such as prior surgery, obesity, and male gender.

For laparoscopic rectal cancer surgery, there are fewer studies to evaluate the oncological outcomes. However, several series have shown prominent results with laparoscopic approach. Morino et al. reported a prospective series of 100 consecutive laparoscopic TME for middle and low position rectal tumors. The conversion rate was 12 %, anastomotic leak rate was 17 %, and overall postoperative morbidity was 36 %. With a median follow-up of 46 months, the port site metastasis rate was 1.4 % and the overall local recurrence rate was 4.2 %. Five-year survival rates for stage I, II, and III disease were 92 %, 79 %, and 67 %, respectively. This series reveals that the oncological outcomes are equivalent to open published series [21].

Dulucq et al. reported their 12-year experience of 218 patients with a mean follow-up of 57 months. Seventy six patients underwent laparoscopic anterior resection and 142 patients underwent laparoscopic TME. Their conversion rate was 12 % and anastomotic leak rate was 10.5 %, and no port site metastases occurred. The local recurrence rate was 6.8 %. Overall survival rate was 67 % at 5 years and 53 % at 10 years. The short-term complication rate and the long-term oncological outcome in this series are comparable with their prior open reports. Although a case series, this study also forcefully reveals that laparoscopic anterior resection and TME with anal sphincter preservation of rectal cancer can be safe and effectively performed by experts [22].

Kim et al. conducted a series of 312 patients who underwent laparoscopic rectal cancer resection performed by a single surgeon. The conversion rate was 2.6 %, anastomotic leak rate was 6.4 %, and overall morbidity rate was 21 %. Sphincter-preserving surgery was performed in 86 %. The circumferential resection margin positivity rate was 4.2 %. Even though only six patients received preoperative radiotherapy, the recurrence rate was 2.9 % at a mean follow-up of 30 months. No port site recurrence was observed. This report demonstrated that laparoscopic rectal cancer resection can achieve remarkable short- and long-term outcomes in highly skilled surgeon [23].

A meta-analysis carried by Heriot et al. was recently published. The data of all the studies between 1993 and 2004 which compared open and laparoscopic surgery for rectal cancer were pooled and analyzed. Overall, 2,071 patients in 20 studies matched the selection criteria. 990 (44 %) patients underwent laparoscopic surgery and 1,162 (56 %) patients underwent open surgery for rectal cancer. This study showed that there was equivalent in oncologic clearance between laparoscopic and open surgery. However, there were some short-term benefits linked with laparoscopic surgery. It was found that time to first bowel movement, feeding solids, and lengths of hospital stay remarkably reduced after laparoscopic surgery. In abdominoperineal resections patients, wound infection and requirement for postoperative analgesia were also prominently reduced in the laparoscopic group. This study demonstrated that laparoscopic rectal cancer surgery results in a resected specimen that is oncologically equivalent to open surgery and a shorter postoperative recovery [24].

The largest comparative randomized trial thus far accruing patients with rectal cancer is the CLASSIC trial (shown in Table 11.2). Unlike the COST study, rectal cancers were included in CLASSIC trial. Seven hundred and ninety-four patients with colon and rectal carcinoma were randomly assigned to laparoscopic and open surgery in a 2:1 fashion. Approximately 50 % of the patients had rectal cancer. The conversion rate for the rectal cancer patient was high at 34 %. The circumferential resection margin positivity rates were higher in patients undergoing laparoscopic anterior resection (12 % vs. 6 %). However, the difference was not statistically significant (P = 0.19). At 3-year follow-up, there were undifferentiated in terms of OS, DFS, or local recurrence between laparoscopic AR and open AR patients. Longer follow-up was recommended but not available to date [10].

Although many reports showed promising outcomes for laparoscopic rectal resection, one has to note that most of these surgeons have surpassed their learning curves and have considerable expertise in laparoscopic surgery. It is difficult to generalize these results. More prospective, randomized studies are recommended for accurate comparison between laparoscopic and open approach for rectal cancer. Several other groups have published similarly excellent results, pending the completion of prospective randomized trials addressing laparoscopy for rectal cancer [25–28].