Role of Laparoscopic Techniques in Colorectal Cancer Surgery

Role of Laparoscopic Techniques in Colorectal Cancer Surgery

ABSTRACT: 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. [ONCOLOGY 9(5):393-409, 1995]


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 [3]. 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 [4]. 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.

Current Indications for Laparoscopic
Intestinal Surgery

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 [8].
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 Laparoscopic
Intestinal Resection

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 [9].

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.

Laparoscopic Colorectal Cancer

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

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.


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