Hybrid laparo-endoscopic techniques for challenging colorectal lesions: a systematic review

Background: Colorectal cancer screening has increased the detection of polyps requiring resection, but standard endoscopic techniques such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) are often unsuitable for large, fibrotic, or anatomically challenging lesions. Segmental colectomy remains definitive but carries substantial morbidity, particularly for benign disease. Laparo-endoscopic cooperative surgery (LECS) and related hybrid techniques have emerged as minimally invasive alternatives bridging the gap between endoscopic and surgical resection. Methods: A systematic review was performed according to PRISMA guidelines, querying PubMed, Embase, and Cochrane databases (1985-2024). Studies reporting combined laparoscopic-endoscopic resections for colorectal lesions unsuitable for standard endoscopic treatment were included. Outcomes assessed included additional surgery, adenocarcinoma detection, complication rates, surgery for complications, conversion to open surgery, and recurrence. Random-effects models were used to calculate pooled proportions and 95% confidence intervals (CIs). Results: Twenty-seven studies encompassing 1112 patients were included. The pooled rate of additional surgery was 5% (95% CI 3-8%; I2 = 0%), including 7% (95% CI 5-9%) for oncologic indications. Adenocarcinoma was identified in 12% of resected lesions (95% CI 8-16%), underscoring limitations of preoperative staging. Overall complications occurred in 7% (95% CI 5-10%), with surgery for complications required in only 1% (95% CI 0-2%). Conversion to open surgery occurred in 2% (95% CI 1-3%). Long-term follow-up demonstrated a local recurrence rate of 3% (95% CI 2-6%; I2 = 0%). Conclusions: Hybrid laparoscopic-endoscopic resections are safe, effective, and reproducible options for complex colorectal lesions not amenable to standard endoscopic resection. These techniques achieve low complication and recurrence rates while preserving bowel and minimizing morbidity associated with colectomy. Given the 12% incidence of unexpected adenocarcinoma, intraoperative adaptability and multidisciplinary expertise are essential. Prospective multicenter studies with standardized reporting are needed to refine patient selection and confirm long-term oncologic safety.