Clinical Status of Laparoscopic Bowel Surgery for GI Malignancy
Clinical Status of Laparoscopic Bowel Surgery for GI Malignancy
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
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.
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, 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 revealed a
diagnostic yield of 90%, staging accuracy of 30%, and understaging in
4% of patients.
A recent study by Hünerbein et al 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
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 surgeons
definition of resectability or operability, and also on the
availability of and expertise with other imaging modalities at each hospital.
Second-look laparoscopy in colorectal and other GI cancers is still
controversial. Hemming et al reported success in proving
peritoneal recurrence of colorectal cancer in two of three
laparoscopies in patients with rising tumor markers and normal
Salky et al 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 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. 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.
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. 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 surgeons 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.
Similarly, cases have been reported in which postoperative bowel
obstruction requiring laparotomy was caused by an unrecognized
synchronous proximal tumor.
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.
It has been hypothesized that laparoscopy, given its minimally
invasive nature, inherently decreases postoperative adhesion
formation. Bessler et al 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. 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.