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Dis Colon Rectum. 2019 Sep 20. doi: 10.1097/DCR.0000000000001490. [Epub ahead of print]

Factors Predicting Operative Difficulty of Laparoscopic Total Mesorectal Excision.

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Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, United Kingdom.
Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, United Kingdom.
Department of Radiology, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, United Kingdom.
Department of Colorectal Surgery, Queen Alexandra Hospital, Cosham, Portsmouth, United Kingdom.
Academic Surgical Unit, University of Southampton, Southampton General Hospital, United Kingdom.
Faculty of Science, University of Bath, Wessex House, Bath, United Kingdom.



Laparoscopic total mesorectal excision is a challenging procedure requiring high-quality surgery for optimal outcomes. Patient, tumor, and pelvic factors are believed to determine difficulty, but previous studies were limited to postoperative data.


This study aimed to report factors predicting laparoscopic total mesorectal excision performance by using objective intraoperative assessment.


Data from a multicenter laparoscopic total mesorectal excision randomized trial (ISRCTN59485808) were reviewed.


This study was conducted at 4 centers in the United Kingdom.


A total of 71 patients underwent elective laparoscopic total mesorectal excision for rectal adenocarcinoma with curative intent: 53% were men, mean age was 69 years, body mass index was 27.7, tumor height was 8.5 cm, 24% underwent neoadjuvant therapy, and 25% had previous surgery.


Surgical performance was assessed through the identification of intraoperative adverse events by using observational clinical human reliability analysis. Univariate analysis and multivariate binomial regression were performed to establish factors predicting the number of intraoperative errors, surgeon-reported case difficulty, and short-term clinical and histopathological outcomes.


A total of 1331 intraoperative errors were identified from 365 hours of surgery (median, 18 per case; interquartile range, 16-22; and range, 9-49). No patient, tumor, or bony pelvimetry measurement correlated with total or pelvic error count, surgeon-reported case difficulty, cognitive load, operative data, specimen quality, number or severity of 30-day morbidity events and length of stay (all r not exceeding ±0.26, p > 0.05). Mesorectal area was associated with major intraoperative adverse events (OR, 1.09; 95%CI, 1.01-1.16; p = 0.015) and postoperative morbidity (OR, 1.1; 95% CI, 1.01-1.2; p = 0.033). Obese men were subjectively reported as harder cases (24 vs 36 mm, p = 0.042), but no detrimental effects on performance or outcomes were seen.


Our sample size is modest, risking type II errors and overfitting of the statistical models.


Patient, tumor, and bony pelvic anatomical characteristics are not seen to influence laparoscopic total mesorectal excision operative difficulty. Mesorectal area is identified as a risk factor for intraoperative and postoperative morbidity. See Video Abstract at

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