This is a retrospective review of all patients who were diagnosed with sigmoid, rectosigmoid, upper rectal, or midrectal cancer undergoing elective LAAR or OAR at the Hospital Sultanah Aminah Colorectal Surgery Unit, Malaysia between October 2017 and November 2018.

All patients were examined with a colonoscopy, confirmed positive histology results of colorectal cancer, contrast computed tomography (CT) scan of thorax, abdomen, and pelvis for staging prior to surgery. After these examinations were performed, the results were evaluated by the colorectal consultant surgeon and the decision for upfront surgery or neo-adjuvant chemotherapy was made. Generally, preoperative chemotherapy was given to patients with fixed T4 disease. Laparoscopic resections were performed based on (1) the anticipated difficulty during laparoscopic surgery due to previous abdominal surgeries; (2) evidence of possible tumor infiltration to surrounding organs on the contrast CT scan and (3) the choice and preference of the patient. The surgical approach was decided by the surgeon and patient after understanding the risks and benefits of each procedure. The study was conducted in compliance with the ethical principles outlined in the Declaration of Helsinki and Malaysian Good Clinical Practice Guideline. Permission from the local Institutional Review Board, the hospital director and head of the Department of General Surgery was obtained prior to the collection of data. Ethical approval was granted by the Ministry of Health Malaysia Medical Research Ethics Committee (KKM/NIHSEC/P19-2163). As patient data were collected anonymously, informed consent was waived and not required. A flowchart showing inclusion and exclusion criteria is presented in Fig. 1.

Surgical resections were classified as OAR or LAAR. The majority of the surgeries were performed by the sole consultant colorectal surgeon and the remainder of cases by the colorectal fellow in training under direct supervision. There have been numerous publications describing the operative technique for OAR and LAAR [8]. The fundamental principles of en bloc resection with curative intent for each procedure were strictly adhered [9]. Independent of the surgical approach, mobilization of the rectum and colon was performed with LigaSure (ValleyLab, Inc., Boulder, CO, USA) or Harmonic (Ethicon Endo-Surgery, Inc., Cincinnati, OH, USA) for the laparoscopic approach and diathermy in the open approach. By using 4-trocars, the inferior mesenteric artery was ligated after identification of the left ureter followed by retromesenteric dissection using a medial to lateral route. For every case, we performed a high ligation of the inferior mesenteric artery taking the branch of the left colic vessels. However, if added length for a tension-free colorectal anastomosis was required, high ligation of the inferior mesenteric artery was performed at the level of the ligament of Treitz. The splenic flexure was later mobilized and followed by laparoscopic total mesorectum excision (TME) with preservation of the hypogastric plexus and nerves. A level of distal colonic transection with a gross estimation of at least 2 cm away from the tumor together with intact mesorectum was considered adequate. The rectum was transected with an endoscopic or conventional stapler through a low abdominal transverse incision. TME was performed in patients with midrectal cancer and partial mesorectal excision for more proximal tumors. Colorectal anastomosis was performed using a double-stapling technique and end-to-end anastomosis using Proximate ILS (Ethicon Endo-Surgery, Inc.) [10, 11]. Proximal diversion was not routinely performed on our patients and was only considered if the anastomosis was hazardous. All patients included had curative surgery which is defined as the removal of all macroscopic disease at the end of surgery [12]. For patients with distant metastatic disease, surgery was still considered curative if the synchronous metastases were completely removed in the same setting or in subsequent operations [13].

In our centre, there is a strict adherence to the enhance recovery after surgery protocol [14]. All patients planned for elective colorectal surgery have to be reviewed by the physiotherapist and dietician teams. The role of the physiotherapist is to assess muscle strength and educate patients on early deep breathing exercises via incentive spirometry with other exercises according to individual patients. The role of the dietician was to assess the nutritional status of the patient and advise on the optimum polymeric diet prior to surgery. All patients were advised to wear thrombo-embolic-deterrent stockings starting from the day of admission for surgery. Bowel preparation was performed 2 days prior to surgery using Fortrans (Ipsen Pharma, Paris, France). On the day of surgery, patients were allowed nourishing fluids until 2 hours prior to surgery with Carborie (Valens Nutrition, Kuala Lumpur, Malaysia) loading 10 hours and 2 hours prior to surgery. If there were no complications, patients were allowed clear fluids on postoperative day 1 and titrated to full diet according to individual patients.

Parameters of interest were divided into patient demography, operative/postoperative details and histopathology variables. Patient demography included patients age, sex, race, source of referral, chief complaint, comorbidities, and any family history of colonic cancer. Operative/postoperative details were mean duration of surgery, length of stay, and postoperative complications. Histopathology variables of interest were type of cancer, tumor differentiation, lymphatic invasion, proximal, distal, and circumferential margin.

Data were analysed using SPSS ver. 16.0 (SPSS Inc, Chicago, IL, USA). All continuous variables were expressed as median with interquartile range and categorical variables were expressed as frequencies and percentages. Each variable was tested for differences between OAR and LAAR using univariate analysis. Categorical data were analysed with chi-square or Fisher exact tests when more than 20% of cells had expected frequencies <5 and continuous variables were analysed with the Mann-Whitney test. All P-values less than 0.05 were considered statistically significant.

Colorectal cancer is the third leading cause of death in Malaysia and is the commonest cancer in both females and males in the developed nations of Europe, America, Asia, and Australia [4,7]. The mainstay treatment remains resection of the tumor-bearing segment of the colon with wide tumor-free resection margins and systematic lymphadenectomy [4,15]. In respect to surgery details, patients who were subjected to laparoscopic surgery had to wait longer from the time of their first visit to the time of surgery. This is due to the necessity of the laparoscopic device energy, trocars, and bowel stapling devices. An application to purchase these devices was sought from the financial aid given by the Malaysian government cancer societies [16]. Therefore, the waiting time for surgery in these patients was longer. Although statistically insignificant and similar to published results, patients in the laparoscopic group had a shorter mean hospital stay of 1.5 days compared to patients in the open surgery group [4,17]. This is due to the earlier recovery of bowel function and reintroduction of oral feeding [18]. Cochrane analysis in 8 studies, which included 1,116 patients, revealed that the duration of postoperative ileus associated with postoperative return of bowel function was one day earlier than the open colorectal resection group [4]. Another important aspect is due to the lowered postoperative intake of analgesia and lung recovery. This is evidenced by a randomized control trial by Schwenk et al. [4] that showed superior forced vital capacity and forced expiratory volume in one second in patients who underwent laparoscopic colectomies. These results were more evident on postoperative day 3 which showed 131 patients with significant improvement in forced vital capacity [4]. Presumably due to the superior lung functions, which led to lower pulmonary complications (such as, atelectasis and pneumonia) and may explain the shorter mean hospital stay [4]. Other postulates of shorter hospital stay are due to the better preservation of systemic immune response caused by less tissue contact and injury in laparoscopic anterior resections [19]. Our results were statistically insignificant but showed a shorter length of stay. This is attributed to our small sample size. However, this showed the feasibility and potential benefits of laparoscopic surgery in our local surgical colorectal unit. We also audited the complication rates at our centre. Two recorded anastomotic leaks (8.7%) and one deep organ space surgical site infection were seen in the OAR group. In the laparoscopic group, only 2 complications were recorded, which were a superficial site infection and enterocutaneous fistula. The anastomotic leak results were higher than in a publication by Hong et al. [13], which only recorded 4 anastomotic leaks (0.81%) from a total of 246 patients. We could not come to a solid conclusion from this result as this is a retrospective audit and patient selection was not standardized.

From our audit, we found that there were equivalent oncologic outcomes in both the laparoscopic and OAR group. From the histopathological results, tumor margin length (proximal and distal) and circumferential radial margin were almost identical in both the laparoscopic and open groups. All patients had a complete histopathological report. This result is similar to multiple studies and laparoscopic surgery is feasible with good surgical training in colorectal subspecialty [20]. West et al. [20] showed that the adoption of surgical education in central vascular ligation led to significant results, including a greater length of colonic specimen, greater distance between tumor and vascular tie and a higher yield of mesenteric lymph nodes (P < 0.001). Throughout our study duration, there were no port site recurrences probably due to the short duration of follow-up and a small number of patients. A reported port site recurrence was seen in 1.9% of patients in a review of 163 patients and this was likely attributed to the traumatic manipulation of the specimen [21]. However, this can be prevented and reduced by tumor bagging and the use of the “no-touch” isolation technique [22].

As of 2013, the incidence and mortality rates of colorectal cancer in Malaysia were 21.3 and 9.79 cases per 100,000 residents [7,23]. The reported incidence and mortality rates of colorectal cancer were higher in the northern states of Malaysia with incidence and mortality rates of 53.18 and 23.07 cases per 100,000 residents. This number is high compared to an incidence rate of 43.7 cases per 100,000 residents in the US and 41.7 cases per 100,000 residents [23]. At present, there are numerous studies published on colorectal cancer in Malaysia [7]. These studies have shown similar demographic data to our results with a similar mean age group of 60–69 years, with Chinese patients and males being the majority of those diagnosed with colorectal cancer [7,23]. However, reports on laparoscopic colorectal surgery in Malaysia are lacking [7]. We could not find any information in the literature published in English on the number of laparoscopic surgeries performed in Malaysia. The only data found were from the Malaysian National Cancer Patient Registry in colorectal cancer [23]. This is the largest registry available but only contains data from 4 out of a total of 14 states in Malaysia. Despite the lack of participation from the majority of other states in Malaysia, this national initiative successfully harvested the records of 3,117 patients [23]. The data revealed that the majority of cancers were located at the sigmoid, rectosigmoid, and rectum (77%). From the 4 states of Malaysia, an average of 66 laparoscopic operations per year were performed from 2008 till 2015 which accounts for 14.9% of the total surgeries performed for colorectal cancers. Despite the high number of patients, there were no detailed data with regard to the type of resection being performed laparoscopically [7,23]. This gives a rough estimate of the local penetration of laparoscopic surgery in Malaysia. Therefore, we hope that our study, which is from the southern state of Malaysia, may help consolidate and create awareness of local laparoscopic colorectal resection.

This is a retrospective audit which is liable to have missing data and bias as patient selection were not standardized. Our hospital still relies heavily on handwritten clinical notes; therefore, another reason for missing data or misinterpretation was due to poor handwriting. To overcome this, the sample population from the colorectal surgery database was only from 1 year (October 2017 to November 2018). The colorectal consultant and operating surgeon responsible for the majority of these cases prior to data entry was consulted if any clinical data were in doubt. Other notable limitations were the exclusion of patients who were converted to open surgery. These data were not captured as the main objective in this study was to compare the outcomes of open and laparoscopic anterior resection.

In conclusion, this retrospective audit suggests laparoscopic anterior resection is feasible in a local Malaysian colorectal surgery unit. The observed benefits were a shorter length of stay with equivalent oncologic results. This result is similar to those of other international studies. The results are valuable data and laparoscopic anterior resection should be offered to patients who fit the eligibility criteria in a well-trained colorectal surgery centre. In light of this data, we hope that this paper may create more awareness of laparoscopic colorectal surgery in Malaysia.