BOSTONA hybrid approach mixing laparoscopic and open procedures
in surgery for rectal cancer may allow patients a faster recovery,
Richard L. Whelan, MD, said at the American Society of Colon and
Rectal Surgeons annual meeting. The approach uses laparoscopic
methods for splenic flexure takedown in the area near the diaphragm
at the start of the operation and switches to open surgery for
removal of the cancer from the rectum.
This combination can remove as much cancer as conventional surgery,
but with a shorter incision and briefer hospital stay, according to a
retrospective review of Dr. Whelans patients. In an interview
with ONI, he described the review as an interesting
preliminary study that will be followed shortly by a randomized
The whole point of doing the laparoscopic part is that its
better to have a small incision than a larger one, said Dr.
Whelan, associate professor of surgery, Columbia Presbyterian Medical
Center, New York. If we can keep the incision below the
umbilicus, I believe it will result in improved pulmonary function,
greater ambulation, and shorter length of stay.
The retrospective study compared outcomes for 31 patients who had the
hybrid surgery in the last 3 to 6 years with outcomes for 25 patients
who were operated on in a fully open procedure 8 to 9 years ago.
Its not a randomized study or a concurrent one, Dr.
Whelan cautioned, calling it a good comparison nonetheless because
one surgeon did all of the operations.
Neoplasm was diagnosed in 87% of the hybrid patients and 68% of those
who had fully open surgery, with the majority of tumors located 4 cm
to 10 cm from the dentate line. All the patients had splenic flexure
takedown and rectal anastomosis. Low anterior or coloanal resections
were done in 58% of the hybrid group and 68% of the fully open group.
Dr. Whelan and his co-authors found that the hybrid method cut the
mean incision length by more than half: 11 cm vs 24 cm for the fully
open group. The hybrid patients also made faster prog-ress by a day
or two in resuming bowel movements and regular diets. Complication
rates were similar, but the hybrid patients hospital stays were
significantly shorter: 6.1 days vs 11.1 days for the fully open
All that matters in the end is how the patient does, said
Dr. Whelan, emphasizing that the two procedures proved to be equally
successful in removing the cancer. A comparison of specimens from
hybrid and conventional surgery showed no difference in the distal
margins, size, or lymph node status, he said.
While laparoscopic surgery is being tested in a number of clinical
trials for colon cancer, it has been considered less promising for
rectal cancers because of technical difficulties in working around
the complex anatomy near the rectum. Working down in the pelvis
can be difficult, Dr. Whelan acknowledged, explaining that the
hybrid method allows a surgeon to remove the cancer manually using
Located in the left upper quadrant near the diaphragm, the splenic
flexure usually must be mobilized in order to rejoin the remaining
colon and rectum, he said. This can be done laparoscopically;
otherwise, an extension of the incision above the umbilicus is
needed. Upper abdominal incisions, more than lower ones, limit
pulmonary function. The hybrid approach avoids the upper incision.
Dr. Whelan said that, in theory, there may be an oncologic benefit
associated with avoidance of a long incision. Animal studies have
shown that full-length abdominal incisions are associated with more
rapid tumor growth and more metastases than laparoscopy. He stressed
that the current human study neither addressed nor proved this