Role of Laparoscopic Techniques in Colorectal Cancer Surgery
Role of Laparoscopic Techniques in Colorectal Cancer Surgery
Laparoscopic intestinal resection is a relatively new application of endoscopic technology that has evolved as a direct result of the successes and benefits seen with laparoscopic gallbladder surgery. Currently acceptable and feasible laparoscopic intestinal resections include those for diagnostic procedures, fecal diversion, Crohn's disease, diverticulitis, familial polyposis, rectal prolapse, and palliative colorectal cancer surgery. However, the efficacy of laparoscopic resection for curative cancer surgery remains a topic of much debate. Issues surrounding curative laparoscopic oncologic resection include the ability to perform an acceptable oncologic resection, the question of morbidity and mortality compared to conventional surgery, and the problem of port site recurrences. Thus, at present, curative laparoscopic oncologic surgery must be conducted within the framework of a prospective, randomized clinical trial, which includes full informed patient consent.
Human laparoscopy was first performed and documented by Jacobeus in 1910 [1,2]. Although initial laparoscopic procedures were purely diagnostic, in 1933 a therapeutic laparoscopic lysis of adhesions was reported . The major hurdles faced by laparoscopic surgeons of the early 20th century were technologic ones, particularly related to optical equipment.
During the 1950s and 1960s, engineering advances improved the visualization and illumination provided by the laparoscope, culminating in the introduction of video chip technology in the 1980s. Video cameras instantly provided a dramatic, clear, full-color laparoscopic view on high-resolution monitors to everyone in the operating room. With this technical development, a team approach to the performance of complex laparoscopic surgeries became achievable (Figure 1).
In 1985, Mühe reported the first human laparoscopic cholecystectomy in Germany . Shortly thereafter, explosive growth in laparoscopic gallbladder surgery began. Currently, over 85% of cholecystectomies are performed laparoscopically; this translates to over 400,000 of such procedures performed annually in the United States.
Several recent comparative studies have shown that patients who undergo laparoscopic cholecystectomy recover more quickly, have less postoperative pain and shorter hospital stays, and are able to return to preoperative activity levels more quickly than patients who undergo conventional cholecystectomy [5-7]. Evidence of such benefits with laparoscopic cholecystectomy has led to attempts at performing laparoscopic intestinal procedures. However, major differences between the technical aspects of laparoscopic biliary surgery and laparoscopic intestinal surgery make the latter more difficult and hazardous to perform.
Laparoscopic cholecystectomy is a relatively simple procedure that involves removal of an end organ situated within a limited anatomic area. In contrast, the intestine is a large, mobile organ supplied by sizeable blood vessels that may be challenging to expose and control during laparoscopic intervention. Furthermore, the risk of contamination is low in biliary surgery, and benign disease represents the primary indication for such a procedure. The same cannot be said for intestinal surgery, in which intraperitoneal spillage of intestinal contents must be avoided and for which resection of cancer is the primary indication.
In this paper, we will review the potential benefits of laparoscopic intestinal intervention and discuss the application of laparoscopic techniques to the treatment of colorectal cancer. All the benefits seen in laparoscopic cholecystectomy, including faster return of normal bowel function, reduced postoperative stress (in terms of improved postoperative pulmonary function and metabolic status), faster recovery, and the perception of improved quality of life, are goals that surgical teams are striving to attain in the application of laparoscopy to intestinal disorders.
The indications for all types of laparoscopic surgery are the same as those for conventional surgery, since access to the intraperitoneal pathology is the only major difference between the two techniques. In other words, a laparoscopic procedure is not performed solely because it can be done laparoscopically.
At our institution, we have performed laparoscopic intestinal surgeries for diagnostic exploration and biopsy, polyp removal, Crohn's disease, diverticulitis, familial polyposis, fecal diversion, rectal prolapse, and palliative and curative cancer surgery . Currently, all patients undergoing laparoscopic intestinal resection for curative cancer surgery in our institution are participants in a prospective, randomized clinical trial, approved by our institutional review board. Informed written consent is obtained prior to such a procedure.
We have seen obvious advantages of using laparoscopic techniques for diagnostic biopsy and abdominal exploration, and believe that laparoscopy probably has been underutilized for this indication in the past. We have shown that some laparoscopic surgeries can be done expeditiously; the approximate time for laparoscopic stoma creation is 1 hour, and for laparoscopic rectopexy (for treatment of rectal prolapse), 2 hours. Additionally, most patients who undergo laparoscopic procedures have a short hospitalization.
Contraindications to performing laparoscopic intestinal resections include severe cardiopulmonary impairment, portal hypertension, a history of multiple abdominal surgeries in the area of the intended surgery, morbid obesity, coagulopathy, intestinal distention related to obstruction, and pregnancy.
Since pneumoperitoneum has the potential for causing some depression of cardiovascular or pulmonary function, patients who manifest any signs of marginal cardiac reserve, major vascular disease, or severe pulmonary disease should not be considered as candidates for laparoscopic surgery. However, since laparoscopic surgery may lead to less depression of postoperative pulmonary function than conventional surgery, it may be reasonable to consider laparoscopic techniques in certain patients with chronic pulmonary disease, provided that there is careful intraoperative monitoring of pulmonary and cardiac functioning. Likewise, reports have indicated that high-risk cardiac patients can safely undergo laparoscopic cholecystectomy with no apparent increase in cardiovascular complications .
Multiple previous abdominal surgeries may be a contraindication to laparoscopic surgery, as extensive adhesions within the abdominal cavity may render laparoscopic surgery unsafe. Also, laparoscopic surgery can be extremely hazardous in patients with a dilated intestine. In such cases, visualization may be markedly impaired, and the surgical team literally may have no room to work inside the peritoneal cavity.
Morbid obesity represents a common contraindication to advanced laparoscopic surgery. Intra-abdominal fat may make exposure of the intestines extremely difficult, and working through a thick abdominal wall also impairs the surgeon's ability to use laparoscopic instruments. We use the calculation of body-mass index (BMI; weight [kg]/height [m²]) as a guide to determining which patients may be too obese for laparoscopic intervention. Patients who may be candidates for laparoscopic intestinal surgery should have a BMI of 32 or less.
In patients with colorectal cancer who have multiple metastases to the liver and/or other distant sites (precluding curative surgical excision), removal of a short intestinal segment bearing the primary tumor with clear margins is often readily accomplished using laparoscopic techniques. Such limited intestinal resection for palliative reasons is the most feasible laparoscopic oncologic bowel resection, as long as the primary tumor is not too bulky (generally less than 4 to 5 cm in diameter) and is not attached to surrounding organs or tissues. The neophyte laparoscopic surgeon should perform these types of resections before attempting curative resections. If, however, a large tumor has infiltrated into adjacent organs or the body wall and cannot be safely resected en bloc, the surgery should be converted to an "open" procedure.
Other readily performed laparoscopic operations include intraperitoneal intestinal bypass procedures or simple stoma construction in cases with a nonresectable tumor, particularly on the left side of the colon.
The issue of performing curative laparoscopic cancer surgery is considerably more controversial. The foremost question is, "Is it possible to perform an adequate oncologic resection with laparoscopic techniques?" This question cannot be answered definitively until long-term recurrence and survival rates have been determined in a large number of patients undergoing curative laparoscopic cancer surgery. We believe that until conventional and laparoscopic surgery have demonstrated comparable recurrence and survival rates, curative laparoscopic intestinal cancer surgery should be performed only within the confines of a prospective, randomized, controlled clinical trial in which full informed consent is obtained from the participants.