Efficacy of pelvic floor peritoneal reconstruction after laparoscopic resection of middle and low rectal cancer: A meta-analysis

Abstract

BACKGROUND

The incidence of rectal cancer is increasing, and laparoscopic resection is being widely used as the treatment approach. However, postoperative complications remain common and adversely affect outcomes. Although pelvic floor peritoneal reconstruction has been proposed to reduce these complications, its effectiveness remains unclear with no consensus on its routine use in clinical practice.

AIM

To evaluate the efficacy of pelvic floor peritoneal reconstruction in laparoscopic rectal cancer resection, particularly its effect on postoperative complications.

METHODS

A systematic search of PubMed, the Cochrane Library, EMBASE, and MEDLINE was conducted for comparative observational studies on pelvic floor peritoneal reconstruction published between January 2010 and May 2025. Two reviewers independently screened the studies and extracted data. Because all eligible comparative studies were observational cohorts, methodological quality was evaluated using the Newcastle-Ottawa Scale, and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. Risk ratios (RRs) were pooled for dichotomous outcomes and mean differences (MDs) were calculated for hospital stay. Procedure-based subgroup and leave-one-out sensitivity analyses were performed when data permitted.

RESULTS

In total, 11 observational cohort studies involving 3142 patients were included. Pelvic floor peritoneal reconstruction was associated with lower risks of intestinal obstruction (RR = 0.30, 95%CI: 0.18-0.49; P_effect < 0.001; I² = 0%, P_{heterogeneity} = 0.52), internal hernia (RR = 0.36, 95%CI: 0.17-0.79; P_effect = 0.010; I² = 0%, P_{heterogeneity} = 0.52), anastomotic leak (RR = 0.69, 95%CI: 0.51-0.93; P_effect = 0.020; I² = 5%, P_{heterogeneity} = 0.64), and unplanned reoperation (RR = 0.33, 95%CI: 0.19-0.57; P_effect < 0.001; I² = 0%, P_{heterogeneity} = 0.52). Hospital stay favored reconstruction (MD = -2.40 days, 95%CI: -4.33 to -0.47; P_effect = 0.015); however, heterogeneity was substantial (I² = 87%, P_{heterogeneity} < 0.001) and leave-one-out analyses were unstable.

CONCLUSION

Pelvic floor peritoneal reconstruction may be associated with fewer short-term complications after laparoscopic surgery for rectal cancer. The effect on hospital stay is uncertain because of the substantial heterogeneity and sensitivity of individual studies. Technique selection could not be determined from the available evidence.

Key Words: Pelvic floor peritoneal reconstruction; Pelvic peritoneal reconstruction; Rectal cancer; Malignant rectal tumors; Laparoscopic surgery; Meta-analysis

Core Tip: Pelvic floor peritoneal reconstruction is associated with lower pooled risks of intestinal obstruction, internal hernia, anastomotic leakage, and unplanned reoperations. Procedure-specific analyses did not detect a difference between laparoscopic abdominoperineal resection and laparoscopic anterior resection for intestinal obstruction or reoperation; however, the subgroups were small and should not be considered equivalent. The hospital stay estimates were heterogeneous and unstable, and the reconstruction techniques were not sufficiently standardized for comparative ranking. Accordingly, the findings support selective consideration and further prospective evaluation rather than routine use.

INTRODUCTION

Rectal cancer represents a substantial global disease burden, and laparoscopic resection is widely performed in appropriately selected patients[1,2]. After resection of a middle or low rectal tumor, disruption of peritoneal continuity may permit the small bowel to descend into the pelvic dead space, potentially contributing to obstruction, internal hernia, and reoperation[3]. Pelvic floor peritoneal reconstruction is intended to restore the barrier between the abdominal and pelvic cavities; however, practice varies because of technical difficulties and uncertainty regarding its clinical benefit[4]. The available comparative evidence consists predominantly of single-center observational cohorts[5]. laparoscopic abdominoperineal resection (LAPR)/extralevator abdominoperineal excision (ELAPE) and laparoscopic anterior resection (LAR) also leave different residual anatomies, and reported reconstruction approaches include primary suture closure, barbed-suture reconstruction, and tissue flaps or cointerventions[6]. Therefore, we synthesized comparative studies to estimate the associations with short-term postoperative outcomes, examine procedure-specific effects where possible, test the robustness of the hospital stay estimate, and assess the outcome-level certainty of evidence[7-10].

MATERIALS AND METHODS

This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

Literature search strategy

A comprehensive literature search was conducted in PubMed, the Cochrane Library, EMBASE, and MEDLINE from January 2010 to May 2025. Medical Subject Headings and the free-text terms included ‘pelvic floor peritoneal reconstruction and pelvic peritoneum closure”. ‘laparoscopic surgery’, ‘rectal cancer’ and related synonyms. The core search logic is as follows: (pelvic peritoneal reconstruction OR pelvic peritoneal closure) AND (laparoscopic OR Minimally invasive) AND (rectal cancer OR rectal neoplasm). Reference lists of eligible participants studies were also screened.

The retrieved literature was independently screened by two researchers, who cross-verified the extracted data. Any disagreements encountered during the process were resolved through group discussions and, if necessary, a third party was consulted. The extracted data included the first author, publication date, study type, sample size, baseline demographic characteristics, and outcome indicators (intestinal obstruction, internal hernia, anastomotic leak, unplanned reoperation, and length of hospital stay). For studies reporting outcomes in different units, all measurements were standardized to international units to ensure consistency.

Inclusion criteria: (1) Study design: Comparative retrospective or prospective cohort studies evaluating pelvic floor peritoneal reconstruction vs no reconstruction. Randomized trials were eligible if identified; (2) Publicly published journals; (3) Publication language: English; (4) Diagnosis: Rectal cancer, including malignant rectal tumors, excluding other rectal diseases; and (5) Studies comparing pelvic floor peritoneal reconstruction with no reconstruction and reporting at least one prespecified postoperative outcome.

Exclusion criteria: (1) Repeatedly Published studies; (2) Multiple intervention measures; (3) Animals; and (4) Reports without sufficient event counts or continuous outcome data to calculate an effect estimate after attempting to derive the required data from a published report.

Data extraction and quality assessment

The literature was independently screened by two reviewers who crosschecked the extracted data. Disagreements were resolved through discussion and, when necessary, consultation with a third reviewer. The extracted variables included study design, operation (LAPR/ELAPE or LAR), reconstruction material or technique, cointerventions, sample size, baseline characteristics, follow-up, and outcome data. As the eligible comparative studies were observational cohorts, methodological quality was assessed using the Newcastle-Ottawa Scale (NOS; maximum 9 points), covering selection, comparability, and outcome assessment. Scores of 7-9 were considered high quality, and scores of 4-6 were considered moderate quality. The certainty of evidence for each pooled outcome was evaluated using the GRADE approach across the risk of bias, inconsistency, indirectness, imprecision, and publication bias. Observational evidence began with low certainty and was downgraded when warranted.

Statistical analysis

Statistical analyses were performed using RevMan 5.4 (Cochrane Collaboration). Dichotomous outcomes were summarized as risk ratios (RRs), and hospital stay was summarized as the mean difference (MD), each with a 95%CI. Statistical heterogeneity was evaluated using the Cochran’s Q and I² tests. A fixed-effect model was used when I² ≤ 50%; otherwise, a random-effects model was used. The treatment-effect P-value (P_effect) and heterogeneity-test P-value (P_{heterogeneity}) were reported separately. Procedure-specific subgroup analyses were pre-specified for LAPR/ELAPE and LAR, and inter-subgroup differences were evaluated using an interaction test. Technique-based subgroup analyses were planned only when at least two clinically comparable studies used the same reconstruction approach. A leave-one-out sensitivity analysis was performed for each outcome. Hospital stay, study-level procedure, country, study period, ERAS reporting, and discharge criteria were examined as potential sources of heterogeneity. Meta-regression was not performed because only three studies reported hospital stay. Funnel plot findings were interpreted cautiously when fewer than 10 studies were available. Two-sided P_effect < 0.05 was considered statistically significant.

RESULTS

Study selection

In total, 20 English-language records were retrieved from PubMed, MEDLINE, the Cochrane Library, and EMBASE databases. After screening against predefined criteria, 11 comparative observational cohort studies were included[1-11], comprising 3142 participants (1418 reconstructions and 1724 controls). The operation, study design, reconstruction approach, and baseline patient characteristics are summarized in Table 1. The NOS scores ranged from 5 to 7; four studies were rated as high-quality and seven as moderate-quality (Table 2). The study selection process is illustrated in Figure 1.

Figure 1 Results and process of the records screening. PubMed, Cochrane Library, EMBASE, and MEDLINE databases were searched. In total, 20 relevant English records were retrieved after screening based on the inclusion and exclusion criteria; 11 English articles[1-11] met the inclusion criteria.

Table 1 Study, procedure, and reconstruction characteristics, mean ± SD/median (interquartile range).

Ref.	Year	Design	Operation	Reconstruction approach	PC/control (n)	Age, PC/control	Male/female/PC/control
Yan et al[1]	2021	Retrospective cohort	LAPR	Primary pelvic peritoneal suture closure	86/96	61.42 ± 11.75/62.07±12.82	62/24/64/32
Shen et al[2]	2021	Retrospective cohort	LAPR/ELAPE	Primary pelvic peritoneal closure	79/21	58 (26-78)/62 (30–91)	47/32/10/11
Li et al[3]	2021	Retrospective PSM cohort	LAR	Primary pelvic peritoneal closure	292/292	59 ± 2.1/61 ± 1.9	161/131/168/124
Wang et al[4]	2018	Retrospective cohort	LAR (Dixon)	Pelvic peritonization by suture	92/97	62.23 ± 4.34/62.45 ± 4.89	56/36/60/37
Ji et al[5]	2022	Prospective cohort	LAR	Continuous barbed-suture reconstruction	58/172	58.4 ± 11.1/59.5 ± 11.0	35/23/105/67
Han et al[6]	2023	Retrospective cohort	LAR	Pelvic peritoneal reconstruction	48/49	61.25 ± 10.38/59.47 ± 11.40	29/19/27/22
Gao et al[7]	2021	Retrospective PSM cohort	LAR	Pelvic peritoneal reconstruction	153/153	61 (51-67)/60 (52-67)	100/53/99/54
Hultman et al[8]	2010	Retrospective cohort	APR/ELAPE	Pedicled omental flap reconstruction	29/41	59.9/57.8	Not reported
Li et al[9]	2025	Retrospective cohort	LAPR	Extraperitoneal colostomy + peritoneal closure	98/64	60.13 ± 10.09/62.09 ± 9.18	57/41/38/26
Shen et al[10]	2022	Retrospective cohort	LAPR/ELAPE	Primary pelvic peritoneal closure	82/22	Not reported	Not reported
Fu et al[11]	2024	Retrospective cohort	LAR	Pelvic floor peritoneal suture closure	401/717	58 (51-65)/59 (49-65)	268/133/460/257

Reconstruction approaches have been reported, as described in the source articles. PC: Pelvic floor peritoneal reconstruction; PSM: Propensity score matching; LAPR: Laparoscopic abdominoperineal resection; ELAPE: Extralevator abdominoperineal excision; LAR: Laparoscopic anterior resection.

Table 2 Quality evaluation of all the included studies.

Ref.	Study design	NOS score (0-9)	Quality rating
Yan et al[1]	Retrospective cohort	6	Moderate
Shen et al[2]	Retrospective cohort	6	Moderate
Li et al[3]	Retrospective PSM cohort	7	High
Wang et al[4]	Retrospective cohort	6	Moderate
Ji et al[5]	Prospective cohort	7	High
Han et al[6]	Retrospective cohort	6	Moderate
Gao et al[7]	Retrospective PSM cohort	6	Moderate
Hultman et al[8]	Retrospective cohort	5	Moderate
Li et al[9]	Retrospective cohort	5	Moderate
Shen et al[10]	Retrospective cohort	7	High
Fu et al[11]	Retrospective cohort	7	High

PSM: Propensity score matching; NOS: Newcastle-Ottawa Scale. Scores of 7-9 were rated as high quality and 4-6 as moderate quality.

Meta-analysis results

Intestinal obstruction: Nine studies reported post-operative intestinal obstruction[1,2,4,6-11]. Heterogeneity was low (I² = 0%, P_{heterogeneity} = 0.52), and the fixed-effect estimate favored reconstruction (RR = 0.30, 95%CI: 0.18-0.49; P_effect < 0.001; Figure 2A). In the procedure subgroups, the estimates were RR = 0.25 (95%CI: 0.12-0.52; P_effect < 0.001; I² = 0%, P_{heterogeneity} = 0.85) for LAPR/ELAPE (Figure 2B) and RR = 0.34 (95%CI: 0.17-0.70; P_effect = 0.003; I²= 32%, P_{heterogeneity} = 0.21) for LAR (Figure 2C). The interaction test did not identify a statistically detectable subgroup difference (P_interaction = 0.55), although the analysis was underpowered. The funnel plot is shown in Figure 3 Visual inspection did not show marked asymmetry; however, as fewer than 10 studies were available, publication bias cannot be excluded.

Figure 2 Forest plot. A: Comparing the risk of postoperative intestinal obstruction between the reconstruction and control groups. The pooled association was relative risk (RR) = 0.30 (95%CI: 0.18-0.49, P_effect < 0.001), with I² = 0% and P_{heterogeneity} = 0.52. A fixed-effect model was used; B: Comparing the risk of postoperative intestinal obstruction following laparoscopic abdominoperineal resection (LAPR) between the reconstruction and control groups. For LAPR/extralevator abdominoperineal excision (ELAPE), the pooled association was RR = 0.25 (95%CI: 0.12-0.52; P_effect < 0.001), with I² = 0% and P_{heterogeneity} = 0.85; a fixed-effect model was used; C: Comparing the risk of postoperative intestinal obstruction following laparoscopic anterior rectal resection (LAR) between the reconstruction and control groups. For LAR, the pooled association was RR = 0.34 (95%CI: 0.17-0.70; P_effect = 0.003) with I² = 32% and P_{heterogeneity} = 0.21; a fixed-effect model was used; D: Comparing the risk of postoperative internal hernia between the reconstruction and control groups. The pooled association was RR = 0.36 (95%CI: 0.17-0.79; P_effect = 0.010), with I² = 0% and P_{heterogeneity} = 0.52; a fixed-effect model was used; E: Comparing the risk of postoperative anastomotic leak between the reconstruction and control groups. The pooled association was RR = 0.69 (95%CI: 0.51-0.93; P_effect = 0.020), with I² = 5% and P_{heterogeneity} = 0.64; a fixed-effect model was used; F: Comparing the risk of postoperative unplanned reoperations between the reconstruction and control groups. The pooled association was RR = 0.33 (95%CI: 0.19-0.57; P_effect < 0.001), with I² = 0% and P_{heterogeneity} = 0.52; a fixed-effect model was used; G: Comparing the risk of unplanned reoperations following LAPR between the reconstruction and control groups. For LAPR/ELAPE, the pooled association was RR = 0.40 (95%CI: 0.16-0.98; P_effect = 0.046), with I² = 38% and P_{heterogeneity} = 0.20; a fixed-effect model was used; H: Comparing the risk of unplanned reoperations following LAR between the reconstruction and control groups. For LAR, the pooled association was RR = 0.30 (95%CI: 0.15-0.60; P_effect < 0.001), with I² = 0% and P_{heterogeneity} = 0.78; a fixed-effect model was used; I: Comparing postoperative length of hospital stay between the reconstruction and control groups. The random-effects estimate was MD = -2.40 days (95%CI: -4.33 to -0.47; P_effect = 0.015), with I² = 87% and P_{heterogeneity} < 0.001. The results were unstable in leave-one-out sensitivity analyses. PC: Pelvic floor peritoneal reconstruction.

Figure 3 Funnel plot of the risk of intestinal obstruction. Visual inspection did not show marked asymmetry. However, with only nine studies, the funnel plot had limited power, and publication bias could not be excluded. RR: Relative risk.

Internal hernia: Five studies[1,2,8-10] reported postoperative internal hernias. Heterogeneity was low (I² = 0%, P_{heterogeneity} = 0.52), and the fixed-effect estimate favored reconstruction (RR = 0.36, 95%CI: 0.17-0.79; P_effect = 0.010; Figure 2D). Because the events were sparse and all data were obtained from observational studies, this association was interpreted with caution.

Anastomotic leak: Seven studies[3-8,11] reported postoperative anastomotic leaks. Heterogeneity was low (I² = 5%, P_{heterogeneity} = 0.64), and the fixed-effect estimate was RR = 0.69 (95%CI: 0.51-0.93; P_effect = 0.020; Figure 2E). This outcome primarily pertains to sphincter-preserving anterior resection and should not be mechanistically generalized to LAPR, in which no colorectal anastomosis is created.

Unplanned reoperation: Six studies[1-3,7,8,11] reported unplanned reoperations. Heterogeneity was low (I² = 0%, P_{heterogeneity} = 0.52), and the fixed-effect estimate favored reconstruction (RR = 0.33, 95%CI: 0.19-0.57; P_effect < 0.001; Figure 2E). The procedure-specific estimates were RR = 0.40 (95%CI: 0.16-0.98; P_effect = 0.046; I² = 38%, P_{heterogeneity} = 0.20) for LAPR/ELAPE (Figure 2F) and RR = 0.30 (95%CI: 0.15-0.60; P_effect < 0.001; I² = 0%, P_{heterogeneity} = 0.78) for LAR (Figure 2H). No statistically detectable subgroup interactions were found (P_interaction = 0.62); however, the small number of observational studies limited this comparison.

Length of hospital stay: Three studies[1,3,9] reported the postoperative hospital stay. The random-effects estimate favored reconstruction (MD = -2.40 days, 95%CI: -4.33 to -0.47; P_effect = 0.015; Figure 2I); however, heterogeneity was substantial (I² = 87%, P_{heterogeneity} < 0.001). Therefore, this pooled estimate was not considered a stable measure of the expected reduction in hospital stays.

Exploratory heterogeneity and sensitivity analysis for hospital stay: All three hospital-stay studies were conducted in China; therefore, the country subgroup analysis was not informative. The studies differed in the operation (LAR vs LAPR), recruitment period, and perioperative pathways. The Yan et al[1] showed a substantially larger MD (-7.39 days) than those reported in the Li et al[3] (-0.80 days) and Li et al[9] (-1.76 days) studies. After omitting Yan et al[1], the pooled MD was -1.20 days (95%CI: -2.13 to -0.27; I² = 61%). After omitting Li et al[3], the estimate was -4.33 days (95%CI: -9.83 to 1.17; I² = 90%); after omitting Li et al[9], it was -3.87 days (95%CI: -10.32 to 2.57; I² = 93%). As the statistical significance and magnitude changed materially, the hospital stay results were considered unstable. ERAS use and discharge criteria have not been consistently reported in quantitative subgroup analyses (Table 3)[12-27].

Table 3 Summary of main outcomes.

Outcome	Studies	Procedure	Effect (95%CI)	Peffect	I2; Pheterogeneity	Model
Intestinal obstruction	9[1,2,4,6-11]	Overall	RR 0.30 (0.18-0.49)	< 0.001	0%; 0.52	Fixed
Intestinal obstruction	4[1,2,8,10]	LAPR/ELAPE	RR 0.25 (0.12-0.52)	< 0.001	0%; 0.85	Fixed
Intestinal obstruction	5[4,6,7,9,11]	LAR	RR 0.34 (0.17-0.70)	0.003	32%; 0.21	Fixed
Internal hernia	5[1,2,8-10]	Overall	RR 0.36 (0.17-0.79)	0.010	0%; 0.52	Fixed
Anastomotic leak	7[3-8,11]	Primarily LAR	RR 0.69 (0.51-0.93)	0.020	5%; 0.64	Fixed
Unplanned reoperation	6[1-3,7,8,11]	Overall	RR 0.33 (0.19-0.57)	< 0.001	0%; 0.52	Fixed
Unplanned reoperation	3[1,2,8]	LAPR/ELAPE	RR 0.40 (0.16-0.98)	0.046	38%; 0.20	Fixed
Unplanned reoperation	3[3,7,11]	LAR	RR 0.30 (0.15-0.60)	< 0.001	0%; 0.78	Fixed
Hospital stay	3[1,3,9]	Mixed	MD -2.40 (-4.33 to -0.47)	0.015	87%; < 0.001	Random

LAPR: Laparoscopic abdominoperineal resection; ELAPE: Extralevator abdominoperineal excision; LAR: Laparoscopic anterior resection; RR: Relative risk; MD: Mean differences.

Certainty of evidence

Using Grading of Recommendations Assessment, Development and Evaluation (GRADE), the certainty was low for intestinal obstruction and unplanned reoperation and very low for internal hernia, anastomotic leak, and hospital stay (Table 4). Ratings reflected the observational design, residual confounding, sparse events or imprecision, length of hospital stay, serious inconsistency, indirectness, and sensitivity instability.

Table 4 Grading of Recommendations Assessment, Development and Evaluation certainty of evidence.

Outcome	Studies/participants	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Publication bias	Certainty
Intestinal obstruction	9/2328	Observational cohorts	Residual confounding	Not serious	Not serious	Not serious	Undetected; limited power	Low
Internal hernia	5/618	Observational cohorts	Residual confounding	Not serious	Not serious	Serious (sparse events)	Undetected; limited power	Very low
Anastomotic leak	7/2594	Observational cohorts	Residual confounding	Not serious	Serious (procedure-specific)	Serious	Undetected; limited power	Very low
Unplanned reoperation	6/2360	Observational cohorts	Residual confounding	Not serious	Not serious	Not serious	Undetected; limited power	Low
Hospital stay	3/928	Observational cohorts	Residual confounding	Serious (I2 = 87%)	Serious (care pathways)	Serious/unstable	Undetected; limited power	Very low

Observational evidence begins with low certainty. No reliable formal test for publication bias was possible because each outcome included fewer than ten studies.

DISCUSSION

Laparoscopic resection is widely used for middle and low rectal cancers; however, the residual pelvic anatomy differs substantially between sphincter-sacrificing and sphincter-preserving procedures. After LAPR/ELAPE, an empty pelvic cavity and perineal defect may permit small bowel descent and adhesion[28,29], after which the sphincter and colorectal anastomosis remain, and pelvic peritoneal closure may alter bowel position, drainage, or local tension through a different mechanism. These anatomical differences preclude the assumption of a single causal pathway for all operations.

Pooled observational data suggest that reconstruction may be associated with a lower risk of intestinal obstruction, internal hernia, anastomotic leak, and unplanned reoperation[19]. For intestinal obstruction and unplanned reoperation, the LAPR/ELAPE and LAR subgroup estimates were directionally similar and the interaction tests were not statistically significant. However, each subgroup contained few studies, residual confounding was likely, and the absence of an interaction is not evidence that the procedure-specific effects are equivalent. Anastomotic leakage should be interpreted within the LAR, rather than extrapolated to the LAPR.

Reconstruction is not a uniform intervention[12,20-22]. The included studies used primary peritoneal suture closure, barbed-suture reconstruction, omental flap, and closure combined with extraperitoneal colostomy, whereas other techniques described in the wider literature included bladder peritoneal flaps and biological meshes[13-15,23-25]. These approaches differ in terms of materials, tension, dead space management, and co-interventions[26]. As too few clinically comparable studies were available within each category, a valid technique-level meta-analysis could not be performed. Consequently, the present results address reconstruction as a broad strategy and cannot determine how reconstruction should be performed or rank the materials and suturing methods[27]. The hospital stay was the least stable. All three contributing studies were conducted in China, making the country an unlikely statistical explanation; however, they differed in operation and study period, while ERAS implementation, discharge thresholds, and reimbursement pathways were not completely reported. The large Yan et al[1] estimate contrasts with the two smaller estimates. Leave-one-out analysis reduced the pooled MD to -1.20 days (95%CI: -2.13 to -0.27; I² = 61%) after excluding Yan et al[1], whereas exclusion of Li et al[9] or Li et al[3] produced confidence intervals crossing the null. Thus, a random-effects model alone does not resolve clinical heterogeneity, and the expected effect on length of stay remains uncertain. The evidence base is limited by its observational design, mostly single-center recruitment, potential selection and confounding biases, sparse events for some outcomes, variable definitions, and follow-up. GRADE certainty was low for intestinal obstruction and unplanned reoperation and very low for internal hernia, anastomotic leak, and hospital stay. No pooled quality-of-life or patient satisfaction data were available; accordingly, the present study makes no inference regarding patient-reported benefits. Future multicenter prospective studies should standardize the operation, reconstruction material and suturing method, ERAS pathway, discharge criteria[16,30,31], and outcome definitions and should prespecify validated quality of life, bowel function, pain, and satisfaction measures[17,32-35].

CONCLUSION

Pelvic floor peritoneal reconstruction may be associated with fewer short-term complications after laparoscopic surgery for middle and lower rectal cancers; however, the available evidence is observational and of low or very low certainty. Procedure-specific findings for LAPR/ELAPE and LAR should be interpreted separately, and the current data do not identify the preferred reconstruction technique. The apparent reduction in hospital stay is uncertain because of the substantial heterogeneity and unstable sensitivity analyses. Reconstruction may be considered selectively in the context of patient anatomy, operation, surgeon expertise, and local protocols[18,34-35], while adequately powered prospective comparative studies are awaited.