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Laparoscopic Surgery for Colon and Rectal Cancer
Deep Goel, Naresh Garg, V. K. Malik
Minimal access surgery has taken a quantum leap in the last decade and a half. Laparoscopic
cholecystectomy has been proven beyond doubt to be the “gold standard” in the management of
cholelithiasis. Several other laparoscopic procedures have gradually been accepted and are being
practiced by surgeons world wide. Laparoscopic fundoplication, splenectomy, adrenalectomy
and nephrectomy are to name a few. Since Jacob’s first laparoscopic colectomy in 1991 there are
various reports in literature suggesting that minimal access surgery is probably the way forward
in colorectal surgery. Inspite of this belief minimal access surgery for colorectal diseases has not
gained momentum amongst the surgical fraternity. Further the use of laparoscopy for ColoRectal cancers is seen with more skepticism. The factors responsible for such an outlook are
discussed in the following article.
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Steep learning curve
Increased time consumed
Oncologic safety including port site metastasis
Need for a separate incision for specimen retrieval
Intra abdominal vascular control
We must discuss colonic cancer and rectal cancer as two separate diseases though a lot of
concerns are going to be common.
Technical ease and oncological results are bigger challenge for laparoscopic rectal cancer
surgery as compared to laparoscopic colonic cancer surgery. This is because there is wide
operator to operator dependent discrepancy in terms of disease free survival and local recurrence
due to varied surgical technique even in open rectal cancer surgery1,2,3.
Laparoscopy as a tool can be used in two ways. One for thorough abdominal cavity exploration
with simultaneous staging of disease with the help of intraoperative ultrasound. Intraoperative
ultrasound can diagnose liver metastasis which may have been missed by routine preoperative
imaging techniques. This may not alter the plan of resection of primary disease but intent of
resection may change. Moreover the decision of excising the secondary disease may depend
upon number of secondaries, their position and institutional policy and also the resection of
primary disease whether it is curative or palliative.
This is probably the most controversial argument put forward by the surgeons with an antagonist
school of thought. The oncological principles for laparoscopic surgery performed are the same as
that for the open surgery. These involve
 Appropriate vessel ligation
 Adequate resection with 5 cm proximal and distal resection margins
 Radical mesenteric lymphadenectomy
 Creation of a reliable anastomosis, and
Many of these elements have been evaluated in clinical trials and perhaps the most extensively
studied factors have been the number of recovered lymph nodes with the surgical specimens and
the adequacy of the resection margins. A recent meta-analysis4 reviewed five randomized
controlled trials on these issues and found no significant difference between the laparoscopic and
the open approach.
A Cochrane Collaboration review of 7 trials comprising of 688 patients5 also found no
difference in the total number of the lymph nodes retrieved in the two groups with a p value of
0.86. The European Colon Cancer Laparoscopic or Open Resection Study Group (COLOR)
found identical rates of positive resection margins of 2 % between their two groups6 with a p
value of 0.86.The UK Medical Research Council trial of Conventional versus Laparoscopic
Assisted Surgery in Colo-Rectal Cancer (MRC CLASICC)7 reported nonsignificant positive
circumferential resection margins of 7 % and 5 % with p = 0.45 in lap assisted and open
resections respectively. In the COST study8, median numbers of lymph node record were 12 in
both arms.
The surgical technique of colectomy or proctectomy is of grave importance in terms of disease
free survival and local pelvic recurrence. It is technically very challenging for a beginner to be
sure of adequacy of resection. The Laparoscopic Colo-rectal surgery has a very steep learning
curve, having said that the learning curve for open colorectal surgery also is not very easy. It has
been shown in various studies that people doing high volume colorectal surgeries have better
results. In the past decade with the rapid evolution of laparoscopy, the advances in the
laparoscopic instrumentation and energy devices have allowed surgeons to perform the surgery
with greater ease.
Laparoscopic colorectal surgery can be done in thre ways
1. Purely laparoscopic
2. Laparoscopic assisted
3. Hand assisted laparoscopic surgery (HALS)
Purely laparoscopic surgery will require not only mobilization, but vascular control, division of
bowel and restoration of continuity intra-corporially. This may not have any added advantage
over laparoscopic assisted technique as you will have to make an incision at the end of the
procedure to deliver the specimen. Most people think that if we can utilize this incision for
vascular control, resection of bowel and restoration of continuity we can bring down the cost and
time of surgery without compromising on advantages of MAS and oncological principles.
HALS
Another bunch of surgeons feel that if we can put our hand inside abdomen from a convenient
incision we can even mobilize bowel, do blunt dissection, retraction and control hemorrhage
with the help of hand. This not only gives the surgeon sense of security, and tactile feel, but
also bridges the gap between laparoscopic surgery and conventional surgery.
The short term outcomes of laparoscopy in Colo-rectal cancer
The short term outcomes have been studied considering the following aspects
Post–operative pain
Numerous randomized controlled trials have demonstrated a significant reduction in pain or
analgesic requirements in the immediate post-operative period. In a meta-analysis Abraham4 and
coworkers found significant advantages for the laparoscopic colectomy group in pain levels at
rest and during coughing.
Quality of life
Exact QOL between two groups is difficult to measure because of lack of more sensitive and
appropriate instruments. Therefore based on literature the patients experienced better quality of
life with reduced pain in the immediate post-operative period.
Recovery of bowel function
Faster recovery of bowel function is another significant advantage seen in the laparoscopic
group. Schwenk and colleagues5 found that first passage of flatus was 1 day earlier in the
laparoscopic colectomy group (p< 0.0001), and the first bowel movement was 0.9 days earlier
(p< 0.0001). Lacy and colleagues9 demonstrated faster initiation of peristalsis and oral intake in
laparoscopic group.
Length of hospital stay
Length of hospital stay is often dependent upon bowel function recovery and severity of
postoperative pain. There is high level of evidence suggesting laparoscopic group has shorter
stay compared with laparotomy group5.
Cost
Direct costs following the laparoscopic surgery are higher than the open one. However, the
diehard supporters of laparoscopic surgery have argued that the total costs to the society may
actually be lower considering the improved short term and potential long-term outcomes
associated with the minimally access approach. Moreover direct cost in the west depends upon
the theater time consumed, this is not the case in most of Asian countries5.
Long term outcomes
The vast majority of comparative studies published so far have found no significant difference in
the long term outcomes between the laparoscopic and open resections, and case series have
found recurrence in survival data that measure favorably with accepted rates for traditional colon
resections. The long term outcomes have been studied considering the following aspects:
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Tumor recurrence
Disease free survival and
Overall survival.
Lacy and colleagues have published one of the first landmark randomized controlled trials
comparing lap assisted and open resections for the colon cancer reporting tumor recurrences rate
of 17% and 27 % respectively with a non-significant trend favoring lap resection (P=0.07).
Similarly based on an intention-to-treat analysis, the overall mortality rates were not significantly
different between the two groups but the cancer related mortality rates favored the laparoscopic
group. The Lacy group also demonstrated that the overall advantages found with the
laparoscopic approach were attributable to the locally advanced Stage III disease sub-group. The
reason is not exactly known but may be related to immune function alteration with laparoscopy.
Another case series has demonstrated similar survival advantage for locally advanced disease10.
The COST study group demonstrated that laparoscopic colectomy for curable cancer is safe and
at least equivalent to open resection in experienced hands.
Port site metastases and tumor dissemination
In 1993, Alexander and colleagues11 reported a case of wound recurrence after 3 months
following laparoscopic right hemicolectomy for a Dukes C adenocarcinoma. After this there
were flood of reports of increased port site metastasis with laparoscopy for malignancy. In a
critical review of the literature from 2001, Zmora and colleagues12 analyzed total of 16 series of
Laparoscopic colo-rectal resections for carcinoma published between 1993 and 2000, each
comprising of greater than 50 patients and found an incidence of port site metastases of less than
1 % among 1737 patients. More recently the data from well designed randomized controlled
trials have provided definitive evidence against a higher incidence of port site metastasis in
laparoscopic colon surgery compared with traditional resection. The Clinical Outcomes of
Surgical Therapy (COST) study8 reported a wound recurrence rate of 0.5% in laparoscopy group
compared with a 0.2% in the open group (n=872, P=0.50). Lacy and colleagues13 found a single
case of port site recurrence in the laparoscopic group (n=106) as compared to none in the open
group (n= 102) after a median follow up of 43 months. Early high incidence of port metastasis
was probably because enthusiastic laparoscopic surgeons ignored oncological principles.
Another concern is regarding the accidental tumor spillage during laparoscopic colo-rectal
resections that is caused by grasping and manipulating the bowel in the narrow pelvis. The
prevalence of intraoperative tumor cell dissemination that is caused by iatrogenic tumor
perforation or transaction during laparoscopic APR has been reported to be as high as 5%14. At
the moment there are few large studies greater than 50 patients and greater than 3 years follow
up15. In two series16,17 where patients underwent laparoscopic rectal resection for advanced
tumor, local pelvic recurrence rates were 19% and 25%, quite similar to recurrence rate in the
open group.
In CLASICC trial7, 242 rectal resections were performed and conversion rate ranges from 34%
for rectal cancer as opposed to 25% for colonic cancer. Rate of positive margins were not
statistically difficult. This clearly demonstrates that laparoscopic rectal resection even in the
hands of experienced surgeons is more technically demanding than laparoscopic colonic surgery.
Although large randomized, prospective trials may show that experienced laparoscopic
colectomists can achieve good outcomes for patients who have curable intraperitoneal colon
adenocarcinoma, these results can not be extrapolated immediately to patients who have rectal
cancer. Thus it is critical to evaluate immediate pathology and long term oncological results
of laparoscopic proctectomy prospectively before recommending the technique for mass
consumption.
Summary
In the last decade and a half, there has been a rapid technical advancement in laparoscopic
techniques to treat colo-rectal cancer, as surgeons have sought to make laparoscopic colectomy
and proctectomy more and more routine. In addition to the advances in laparoscopic
instrumentation and energy delivery, improvements in hand assist technology have allowed
surgeons to approach laparoscopic proctectomy with better tools. Large randomized, prospective
trials have shown that laparoscopic colectomists in the hands of experienced surgeons can
achieve good outcomes for patients who have curable intraperitoneal colon adenocarcinoma.
These results can not be extrapolated immediately to patients who have rectal cancer.
Laparoscopic proctectomy should remain in the hands of well trained, high volume, experienced
surgeons who have built a dedicated team for treatment of these patients and who follow them
prospectively.
References
1. Read TE, Myerson RJ, Fleshman JW et al. Surgeon specialty is associated with outcome
in rectal cancer treatment. Dis Colon Rectum 2002;45:904-14.
2. Porter GA, Soskolne CL. Yakimets WW et al. Surgeon-related factors and outcome in
rectal cancer. Ann Surg 1998;227:157-67.
3. McArdle CS, Hole D. Impact of variability among surgeons on postoperative morbidity
and mortality and ultimate survival. BMJ 1991;302:1501-5.
4. Abraham NS, Young JM, Solomon MJ. Meta-analysis of shortterm outcomes after
laparoscopic resection for colorectal cancer. Br J Surg 2004;91:1111-24.
5. Schwenk W, Haase O, Neudecker J et al. Short term benefits of laparoscopic colorectal
resection. Cochrane Database Syst Rev 2005;(3):CD003145.
6. The Colon Cancer Laparosocpic or Open Resection Study Group. Laparoscopic surgery
versus open surgery for colon cancer: shortterm outcomes of a randomized trial. Lancet
Oncol 2005;6:477-84.
7. Guillou PJ, Quirke P, Thorpe H et al. Short-term endpoints of conventional versus
laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC Trial):
multicentre, randomized controlled trial. Lancet 2005;365:1718-26.
8. The Clinical Outcomes of Surgical Therapy Study Group. A comparison of
laparoscopically assisted and open colectomy for colon cancer. N Engl J Med
2004;350:2050-9.
9. Lacy A, Garcia-Valdecasas J, Delgado S et al. Postoperative complications of
laparoscopic-assisted colectomy. Surg Endosc 1996;11:119-22.
10. Poulin EC, Mamazza J, Schlachta CM et al. Laparoscopic resection does not adversely
affect early survival curves in patients undergoing surgery for colorectal adenocarcinoma.
Ann Surg 1999;229:487-92.
11. Alexander RJ, Jaques BC, Mitchell KG. Laparoscopically assisted colectomy and wound
recurrence. Lancet 1993;341:249-50.
12. Zmora O, Gervaz P, Wexner SD. Trocar site recurrence in laparoscopic surgery for
colorectal cancer: myth or real concern? Surg Endosc 2001;15:788-93.
13. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopyassisted colectomy
versus open colectomy for treatment of non-metastatic colon cancer: a randomized trial.
Lancet 2002;359:2224-9.
14. Kockerling F, Rose J, Schneider C et al. Laparoscopic colorectal anastomosis: risk of
postoperative leakage. Results of a multicenter study. Laparoscopic Colorectal Surgery
Study Group (LCSSG). Surg Endosc 1999;13:639-44.
15. Morino M, Parini Uneventful., Giraudo G et al. Laparoscopic total mesorectal excision: a
consecutive series of 100 patients. Ann Surg 2003;237:335-42.
16. Fleshman JW, Wexner SD, Anvari M, et al. Laparoscopic vs. open abdominoperineal
resection for cancer. Dis Colon Rectum 1999;42:930-9.
17. Lezoche E, Feliciotti F, Paganini AM et al. Results of laparoscopic versus open
resections for non-early rectal cancer in patients with a minimum follow-up of four years.
Hepatogastroenterology 2002;49:1185-90.
18. Fowler DL, White A. Laparoscopy-assisted sigmoid resection. Surg Laparosc Endosc
1991;1:183-8.
19. Lacy A. Colon cancer: laparoscopic resection. Ann Oncol 2005;16(Suppl 2):ii88-95.
20. Milsom JW, Bohm B, Hammerhofer KA, et al. A prospective,randomized trial comparing
laparoscopic versus conventional techniques in colorectal cancer surgery: a preliminary
report. J Am Coll Surg 1998;187:46-57.
21. Kaiser AM, Kang JC, Chan LS et al. Laparoscopic-assisted versus open colectomy for
colon cancer: a prospective randomized trial. J Laparoendosc Adv Surg Tech A
2004;14:1062-6.
22. Pietrabissa A, Moretto C, Carobbi A et al. Hand-assisted laparoscopic low anterior
resection: initial experience with a new procedure. Surg Endosc 2002;16:431-5.
23. Viithiananthan S, Cooper Z, Betten K et al. Hybrid laparoscopic flexure takedown and
open procedure for rectal resection is associated with significantly shorter length of stay
than equivalent open resection. Dis Colon Rectum 2001;44:927-35.
24. Yamamoto S., Watanabe M, Hasegawa H et al. Prospective evaulation of laparoscopic
surgery for rectosigmoidal and rectal carcinoma. Dis Colon Rectum 2002;45:1648-54.
25. Monson JR, Darzi A, Carey PD et al. Prospective evaluation of laparoscopic-assisted
colectomy in an unselected group of patients. Lancet 1992;340:831-3.