Laparoscopic surgery for colorectal cancers : Current status

cholecystectomy in 1987 i France, performed by Philipe Mouret for the first time during a laparoscopic Laparoscopy was introduced more than 15 years ago into clinical practice. However, its role in gynecologic surgery, rapidly established its role in colorectal surgery was not well established for want place of open surgery. [1] However, laparoscopic large of better skills and technology. This coupled with bowel surgery did not, for a long time, receive the high incidences of port site recurrences, prevented same degree of acceptance by the surgical community laparoscopic surgery from being incorporated into although a few of the initial series had shown mainstream colorectal cancer surgery. A recent increase in the number of reports, retrospective promising results. We thus review the problems that analyses, randomized trials and multicentric trials were and are still associated with laparoscopic has now provided sufficient data to support the role surgery for colorectal cancer while finally attempting of laparoscopy in colorectal cancer surgery. We, to provide an evidence-based review of literature to thus, present a review of the published data on the suggest as to where laparoscopic surgery stands feasibility, safety, short and long-term outcomes today in the field of colorectal cancers. following laparoscopic surgery for colorectal cancers. While the data available strongly favors the use of laparoscopic surgery in colonic cancer, Problems associated with laparoscopic surgery larger well powered studies are required to prove or Laparoscopy for colorectal cancers has not gained disprove its role in rectal cancer. universal acceptance for a number of reasons 1. Questions on feasibility: Laparoscopic large bowel


complicated than
The morbidity and mortality associated with surgical procedures performed on the colon and rectum have plagued surgeons since time immemorial.As surgeons began to perform open colorectal surgery with increasing confidence these very same problems assumed high significance until the principles of antisepsis and the refinements in surgical technique began to make a considerable dent in these negative outcomes.At this same time, surgeons had already explored the role of minimal invasiveness in treating colorectal problems, viz. the use of the sigmoidoscope to deflate a sigmoid volvulus, perineal procedures for prolapse in elderly persons, etc.The laparoscopic laparoscopic cholecystectomy with a steeper learning cur ve.It requires more advanced laparoscopic technique.6][7][8] 3. Presence of an anastomosis or stoma prevents rapid discharge from hospital.4. The efficacy of large bowel laparoscopic surgery for cancer with respect to factors like tumor clearance and the fear that laparoscopic surgery enhances tumor dissemination. 5. Safety -this implies that laparoscopic surgery carries with it not only some of the general complications encountered with surgery on the bowel, but also a set of unique complications that

Historical discoveries in the advancement of
Coagulopathy not correctable preoperatively laparoscopy for colorectal surgery [10]

Extreme obesity Pregnancy
Advances in techniques of laparoscopy that have Melotti et al also concluded that the distance of the Videolaparoscopic techniques in colorectal surgery tumor from resection margins and the number of were used for the first time in 1990 by Moises Jacobs lymph nodes harvested with the operative specimen in Miami, Florida while performing a right did not vary from those obtained in open surgery. [14]emicolectomy. [11]The development of a circular A recent meta-analysis [15] showed that the number of

Extent of oncological resection in laparoscopy versus open surgery
The most important aspect if the feasibility of laparoscopy has to be assessed in case of colorectal malignancies is to unconditionally prove that the oncological resection, i.e., the margins of resection proximal, distal and circumferential and the number of nodes harvested are comparable, if not better than in open surgery.

Safety and complications
The introduction of laparoscopy into the armamentarium of surgery for colorectal cancer has brought, along with the novel idea of minimal access, a novel set of complications associated with the creation of pneumoperitoneum, port placement and diathermy use that require a considerable amount of skill as well as specialized training if they have to be prevented.Table 2 lists a few of the specific complications associated with laparoscopic colorectal surgery. [17]Six randomized controlled trials [18][19][20][21][22][23] comparing complication rates did not find any significant difference between laparoscopic and open surgery.In fact, a few did show a lower morbidity in favor of the laparoscopy group.Lacy et al [18]   loss, lymphocyte proliferation in response to Candida albicans and phytohemagglutinin and return to full activity, found that the laparoscopic arm had a significant decrease in the 30-day postoperative morbidity rates compared with the open arm.They also concluded that laparoscopic assisted colorectal surgeries are associated with better preservation of lymphocyte proliferation indices and gut oxygen tension.Tang et al, [30] have shown that there is no difference in the systemic immune response of laparoscopically assisted colectomy and those undergoing conventional open surgery for colorectal that while the operative time was consistently longer cancer.The Cochrane review [31] in the laparoscopic arm, the peri-operative blood loss benefits for laparoscopic colorectal resections which as well as morbidity were significantly lower in the analyzed 22 trials and 2965 participants, concluded laparoscopic arm.Conversion rates vary from 1% [24] that whilst the results available favored laparoscopic The conclusion is clear -laparoscopic colorectal resection, only seven of the trials had surgery, if performed by a trained, skillful surgeon, more than 100 patients.The reviewers believed that will produce results comparable to open surgery.Poor the final verdict could only be given after the technique is responsible for the complications multicenter trials viz, COLOR, MRC CLASICC and encountered and does not reflect an inherent errant LAPKON II (Germany).The results of the COLOR potential in laparoscopic surgery.Conversion is not study [23] have been summarized in Table 3, while a complication and must be resorted to whenever the MRC CLASICC [25] has concluded that laparoscopic assisted surgery for colon cancer is as effective as open surgery and is likely to produce similar long-Short-term outcomes term outcomes.However, impaired short-term shows a comparison between various outcomes after laparoscopic-assisted anterior randomized trials comparing short-term outcomes viz, resection (including CRM positivity) for cancer of the blood loss, analgesic requirement and operative time.
rectum do not justify its routine use.
in their randomized study on short-Long-term outcomes

Bladder injury Ureteral injury Missed lesions patients having
Bowel injury on the short-term to 29%. [25]quired. [17]ble 3 [29] Braga et al, term outcomes in laparoscopic and open surgery, Laparoscopic colorectal surgeries have constantly while analyzing parameters such as wound infection been under scrutiny with respect to the long-term rates, anastomotic leak rates, operative time, blood outcomes -survival data and recurrence rates.The Lacy AM [18] 142 118* 105 193* Hasegawa H [20] 275 188* 58 137* Less* More Leung KL [21] 189.9 144.2*P<0.001 169 238 P=0.06 4.5 (no of inj) 6.9 (no of inj)* P<0.001 Zhou ZG [22] 120 106 20 92* Less More COLOR [23] 145 115* P<0.0001 100 175* P<0.0001 Less* More Curet MJ [26] 210 138* 284 407* COST Group [27] 150 95* Less* More Sahakitrungruang C [28] More data available [32][33][34][35] has shown long-term survival comparable to conventional open surgery.Local recurrence rates vary from 0-6.6%. [18,36,37]Capusotti et al, [33] have even found a better outcome for node positive patients treated by laparoscopy.Jacob et al, [34] have in fact shown better results in the patients undergoing laparoscopic resections.A recent systematic review [38] has shown no difference between Many studies [17,[44][45][46] found a lesser prevalence of port site recurrence than previously shown and realized that the incidence corresponds with wound recurrence seen in open surgery.According to Melotti et al, [14] the incidence of port site metastases varies from 0, in the recent studies, to 21.4% in other limited series. [7]Data in support of laparoscopic surgery have steadily increased blaming the initial reports of poor laparoscopy and open surgery with regard to the long-outcome on poor surgical technique.Some policies term outcome.Other, less powered studies, [39,40] have advised are to avoid contact between laparoscopic shown a better outcome for the laparoscopy arm instruments and the tumor by bagging and the use patients.However, multicenter randomized trials are of "no -touch" isolation technique suggested by RB needed to confirm or refute these results.
Turnbull Jr, [14] meticulous lavage of all wounds with a cytocidal agent, [2] widening the port of extraction Port site recurrence of the specimen and use of wound protectors. [17]fter the first reported port site metastasis in 1978, [41] numerous studies have been carried out to determine Quality of life issues whether laparoscopy is actually associated with an While the operative time for laparoscopic surgery is increased incidence of port site recurrences / obviously more than that for open surgery, there are metastasis.[7][8][9] The possible mechanisms the use of laparoscopy as compared with open which lead to port site metastasis have been surgery.As there is no large abdominal incision, the summarized in Table 4. [42] In the review published in corresponding postoperative pain and the ensuing 1998, Neuhaus et al [42] had strongly suggested an need for analgesia is reduced. [20,23,27,47,48]As the wound increased incidence of port site metastases due to is smaller, the likelihood of wound infection is laparoscopic surgery, warning that in view of the less. [29,49]This attains significance when the patient findings, laparcoscopic surgery for colorectal is a candidate for adjuvant chemotherapy at which malignancies should occur only within the context time, a wound infection can delay institution of the of clinical trials.In a prospective randomized chemotherapy.The COST study has shown better controlled trial, Lacy et al, [43] found no port site short-term quality of life.The recurrence and survival recurrences in the 91 patients studied by them, rates were equivalent for both groups and for all neither in the laparoscopic nor open surgical arms.tumor stages. [27]The median hospital stay and the need for parenteral antibiotics were also shown to be lower in the laparoscopy group.The validity of this shortened hospital stay, though, has been questioned in the light of the stay also being affected by the presence of an anastomosis and the age of the patient.
The incidence of small bowel related problems postoperatively including adhesive obstruction and the incidence of postoperative ventral hernias have also been seen to be on the lower side in the laparoscopically resected group of patients. [50]3] 9. Ramos JM, Gupta S, Anthone GJ, Ortega AE, Simons AJ, Beart RW This has been attributed possibly to the higher ) .
Tumor extensively involving contiguous structures paved the way for a shift in the role of laparoscopic Diffuse peritoneal contamination with perforated viscus surgery in colorectal diseases from the initial Acute inflammatory bowel disease (fever, distension, other signs of toxicity) associated with the malignancy intended role of an adjunct to open surgery, to an Eneroenteric or enterocutaneous fistula important operative modality have been, firstly, the surgeries Obstruction of the intestine with abdominal distension realization of the benefit of such a procedure in elderly patients where the morbidity of the large incision of the number of lymph nodes harvested was open surgery can be overcome by the reduction in comparable between open and laparoscopic surgery.pain and overall bacterial contamination.
n o w P u b l i c a t i o n s ( w w w .m e d k n o w .c o m ) .Shukla PJ, et al.: Laparoscopic surger y for colorectal cancers

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Less* Indicates that the difference was statistically significant Journal of Minimal Access Surgery | December 2006 | Volume 2 et al.: Laparoscopic surger y for colorectal cancers et al.: Laparoscopic surger y for colorectal cancers associated with bladder and sexual dysfunction.An after laparoscopic resection of malignancy.Aust NZ J Surg 1993;63:563-5.

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Laparoscopic and colon cancer: Is the port site at risk?A

Table 1 : Contraindications to laparoscopic colorectal
Shukla PJ, et al.: Laparoscopic surger y for colorectal cancers can occur more or sometimes exclusively only in laparoscopic surgery, e.g., pneumothorax, gas surgery embolism, port site hernias, etc.

Table 1 ]
[12] (4.6 cm in the lap group versus 5.3 cm in the open Dennis Fowler successfully demonstrated this in 1990 group) were statistically significant in favor of open when he performed the first laparoscopic sigmoid surgery.On the basis of correlation they concluded resection.Subsequent years witnessed more that laparoscopic surgery was as adequate as the technical innovations that could now make conventional approach.Bretagnol et al, have shown laparoscopic surgeries on the colon and rectum ( w w w