Clinical Status of Laparoscopic Bowel Surgery for GI Malignancy

Introduction

Since the introduction of laparoscopic cholecystectomy, nearly every surgical specialty and procedure has incorporated the laparoscope. The theoretical benefits of reduced postoperative pain, length of hospital stay, and early return to work, as well as other benefits, however, have not been universally borne out in laparoscopic colorectal surgery.

Also, laparoscopic colorectal surgery is associated with some major problems: (1) laparoscopic colorectal surgery typically involves multiple quadrants and, therefore, is more technically challenging. Personnel, instruments, monitors, and even the patient are often moved to facilitate access to these quadrants; (2) bowel surgery requires rapid and safe manipulation of numerous, large, often calcified vessels, which are always encased in fat; (3) colonic surgery involves fashioning a well-vascularized, tension-free, circumferentially intact anastomosis, without intraperitoneal contamination; and (4) a major indication for laparoscopic colorectal surgery would be malignancy, and the safety and effectiveness of laparoscopy for this indication are currently unknown.

As technology has improved and the skills of surgeons have become more advanced, laparoscopy has been used by some for diagnosis, palliation, and attempted cure of gastrointestinal (GI) tumors. Laparoscopy for curative resection of malignancy is the most controversial indication for laparoscopic surgery today, because true recurrence and overall cure rates remain unknown.

Laparoscopy for Diagnosis and Palliative Surgery

Laparoscopic ultrasonography in patients with GI malignancy presents a unique opportunity for precise tissue sampling. Moreover, the patient can be offered minimally invasive palliative laparoscopic bypass and diversionary procedures.

In a series by Anderson et al,[1] laparoscopic ultrasonography was significantly more accurate than either conventional computed tomography (CT) or ultrasonography in detecting both primary GI tumors (91% vs 64%; P < .01) and nodal status (91% vs 62%; P < .05). A study by Cuschieri[2] revealed a diagnostic yield of 90%, staging accuracy of 30%, and understaging in 4% of patients.

A recent study by Hünerbein et al[3] revealed that laparoscopy and laparoscopic ultrasound improved the accuracy of staging in 41% of patients with GI cancer, as compared with conventional imaging methods; the accuracy of staging laparoscopy in the detection of distant metastases (68%) was significantly higher (P < .01) than that of ultrasound (63%) or CT scan (58%). The findings during staging laparoscopy changed the treatment strategy in 45% of patients.

The exact role of laparoscopy and laparoscopic ultrasonography in the evaluation of specific intra-abdominal malignancies continues to be evaluated. Its clinical effect depends on the surgeon’s definition of resectability or operability, and also on the availability of and expertise with other imaging modalities at each hospital.[4]

Second-Look Laparoscopy

Second-look laparoscopy in colorectal and other GI cancers is still controversial. Hemming et al[5] reported success in proving peritoneal recurrence of colorectal cancer in two of three laparoscopies in patients with rising tumor markers and normal radiologic studies.

Salky et al[6] also attempted second-look laparoscopy in seven patients with suspected recurrent colon cancer, leading to a positive yield in one with liver metastases and avoidance of surgery in all but two. However, these are small numbers of patients, and further investigation in this area is required before such an approach can be recommended.

Laparoscopic Fecal Diversion

Patients with advanced malignancies may undergo fecal diversion to relieve obstruction, incontinence, complicated fistulas, and severe perianal sepsis. Hashizume and colleagues[7] reported a successful laparoscopic-assisted colostomy for complete obstruction of the sigmoid colon associated with end-stage ovarian cancer.

Laparoscopic fecal diversion obviates the need for a major abdominal incision but does not limit intra-abdominal exploration when a trephine stoma is performed.[8] Laparoscopic fecal diversion is technically simple to perform and requires minimal equipment while allowing excellent visualization and all possible methods of dissection.

Some investigators have advocated that laparoscopic fecal diversion procedures be performed by surgeons with limited experience in laparoscopic intestinal surgery. Laparoscopic colostomy may be associated with a decreased incidence of wound complications, evisceration, and incisional hernia, as compared with laparotomy.

Furthermore, the traditional merits of laparoscopy, such as earlier return to bowel function, decreased pain, and, theoretically, reduced adhesion formation, are advantages of laparoscopic fecal diversion.[8, 9] However, in patients with an acute obstruction and massive bowel dilatation or with free intraperitoneal perforation, a laparotomy may be preferable.[10]

Surgical Considerations

Major colorectal resections may be accomplished in two ways: either by right hemicolectomy for ileocolic resections or by total abdominal colectomy. For the latter, if laparoscopy is utilized, the laparoscopic-assisted technique is preferred. After laparoscopic mobilization, the bowel is exteriorized through a small incision for extracorporeal vascular ligation, resection, and anastomosis.

Although these maneuvers can all be performed within the abdomen, the length of operative time and expense limit their attractiveness. Moreover, since an incision needs to be made for specimen retrieval, it seems logical to also perform the ligation, resection, and anastomosis through that incision.

For left-sided procedures, a completely laparoscopic technique is more logical. In such cases, colonic mobilization, resection, and anastomosis are accomplished in an intracorporeal manner.

Length of the Procedure

Laparoscopic colorectal surgery involves a learning curve, during which operative times of over 2 hours can be expected. Operative time decreases with increasing experience.[11] This improvement seems to be the result of both better surgical technique and better patient selection. The use of the ultrasonic scalpel (Harmonic Scapel, Ethicon Endosurgy Inc, Cincinnati, Ohio) offers a definite advantage for mesenteric dissection and vascular control by potentially allowing adequate hemostasis, decreased operative time, and decreased cost because fewer surgical clips are utilized.

Interference With Tactile Sensation

One of the disadvantages of laparoscopic surgery is that it impairs the surgeon’s tactile sensation and the ability to palpate the bowel. Several reports have described the resection of a segment of bowel thought to contain a tumor or polyp, but the suspected lesion was later discovered in an unresected segment of bowel.[12] Similarly, cases have been reported in which postoperative bowel obstruction requiring laparotomy was caused by an unrecognized synchronous proximal tumor.[13]

This problem can be overcome in a number of ways, including preoperative colonoscopic marking, preoperative air contrast barium enema, or intraoperative colonoscopy. Intraoperative laparoscopic ultrasonography offers the surgeon the ability to palpate the liver and other organs, which is lost during the laparoscopic surgery.

This interference with tactile sensation also makes identification of certain anatomic structures more difficult. Accordingly, ureteric catheters are sometimes used to assist in the identification of the ureters.[14]

Postoperative Adhesions

It has been hypothesized that laparoscopy, given its minimally invasive nature, inherently decreases postoperative adhesion formation.[9] Bessler et al[15] reported a porcine model comparing the incidence of adhesion formation after laparotomy compared with laparoscopic-assisted colon resections. Adhesions were identified 14 days after the initial procedure in only one (9%) of the animals that had laparoscopic-assisted resections, as opposed to 82% of the animals that had a laparotomy.

Recently, as part of a multi-institutional, prospectively randomized, surgeon-blinded trial, we assessed postoperative adhesion formation using a hyaluronate-based membrane.[16] The number and severity of adhesions were significantly decreased when the hyaluronate-based membrane was applied, as compared with the control group, both of which underwent laparotomy. The same advantages may be conferred by using the product during laparoscopic-assisted procedures. Accordingly, we routinely place Seprafilm (Gemzyme Surgical Products, Cambridge, Mass) during all laparoscopic-assisted colectomies.