Surgical remedies associated with colorectal cancer are generally determined by the tumor site and degree of tumor extension. Progressions in surgical devices and techniques have assisted surgeons in the anal preservation of many of their patients. Nonetheless, careful resection is still necessary for rectal cancers located in very close proximity near the anus regardless, to secure safer distal and radial margins in the anal canal. Thus, surgical treatment for lower rectal cancer must seek stability between durability and maintenance of function.
On the other hand, abdominoperineal resection (APR) is commonly performed in circumstances when the anus is technically and/or functionally impossible to be preserved. Some paramount anus-preserving surgical methods consist of sphincter muscle resection and intersphincteric resection (ISR) as defined by Schiessel, which is currently highly preferred as a corrective treatment for these specific site cancers and has become universally implemented around the world.
This technique is initiated to avoid permanent colostomy for very low rectal cancers which might previously have required APR.
The ISR procedure comprises both transabdominal and transanal methods. The internal sphincter is transabdominal and transanally divided from the external sphincter by dissecting the intersphincteric space (plane) accompanied by coloanal anastomosis which is then done using a hand-sewn technique. Numerous studies on the surgical, oncologic, and, functional outcomes of patients after ISR have been reported and observed as well. With technical progressions, laparoscopic surgery has confirmed itself with the advantages it holds in treating rectal cancer. Even though the learning curve and technical difficulties have restricted the extensive application of laparoscopic sphincter-preserving TME, laparoscopic ISR is supportive in the management of ultralow rectal cancer.
With the application of this technique, the need for performing abdominoperineal resection appears to have reduced in patients with very low rectal tumors . For this motive, laparoscopic surgery has increasingly gained a strong role in colon cancer treatment . The road to the development of laparoscopic surgery for rectal cancer has been more thought-provoking, due to the technical and anatomical adversities related to this method. It has been clearly exposed that oncological and short term results are similar to open surgery, given the well-recognized benefits of laparoscopy in terms of faster recovery and cosmesis.
The laparoscopic approach to rectal cancer, specifically lower rectal cancer, needs special expertise and should be performed in high volume colorectal cancer centers, since the surgeon is one of the most critical factors for the best outcome and a long learning curve is needed . Moreover, concerning open surgery, laparoscopy permits a better vision in the pelvis. This is significant to attain a good nerve-sparing technique and an appropriate total mesolectal excision, with a clear exposure of the plane between the rectum and the vagina or the seminal vesicles and the prostate, and, finally, of the pelvic floor. This is also true for an ISR since a precise and bloodless up to down dissection can be carried out between the pelvic diaphragm hiatus and the rectum, therefore entering in the intersphincteric space. From the beginning of this century, quite a few experiences with laparoscopic ISR are documented in literature.