Utility of Pelvic Peritoneum Closure After Minimally Invasive Low Anterior Resections for Rectal Cancer. A Systematic Review and Meta-Analysis

BACKGROUND: Anastomotic leakage (AL) after low anterior resection (LAR) remains a major determinant of postoperative morbidity, largely driven by the severity of its downstream consequences. Pelvic peritoneum closure (PC) has been proposed as an anatomy-based maneuver to restore pelvic compartmentalization after LAR, but its clinical impact has not been systematically quantified. METHODS: A systematic review and meta-analysis were conducted according to a prespecified PROSPERO protocol and the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines. PubMed (MEDLINE), Embase, and Scopus were searched from inception to April 2026. Comparative studies evaluating PC versus no closure (NC) after minimally invasive LAR for rectal cancer were included. The primary outcome was severe postoperative complications (Clavien-Dindo grades III-IV). Secondary outcomes included overall postoperative complications, AL, infectious and medical complications, operative time, length of stay, reoperation, mortality, and functional outcomes when available. Risk of bias was assessed using Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I). RESULTS: Seven observational studies encompassing 2753 patients (PC: 1,096; NC: 1,657) were included. PC was associated with a lower risk of severe postoperative complications (odds ratios [OR] 0.34, 95% confidence intervals [CI] 0.20-0.55), with no heterogeneity. Overall postoperative complications did not differ between groups (OR: 0.86, 95% CI: 0.67-1.11). No increase in infectious or medical complications was observed. Operative time was significantly longer with PC (mean difference 11.1 minutes), with substantial heterogeneity. Length of stay and perioperative mortality were comparable between groups. Functional outcomes were reported in a limited number of studies and suggested improved postoperative bowel function after PC. CONCLUSIONS: PC following minimally invasive LAR is associated with a reduction in severe postoperative complications and clinically relevant AL. However, these findings are derived predominantly from observational studies and should be interpreted with caution. Further adequately powered randomized controlled trials are required before routine clinical adoption can be recommended.