Surgery for cancer carries concerns of tumor dissemination related to tumor manipulation, tumor violation, and wound seeding. Minimally invasive surgery is now standard for several benign conditions, such as symptomatic cholelithiasis and surgical therapy of gastroesophageal reflux. With the minimally invasive surgery explosion of the 1990s, virtually every procedure traditionally performed via laparotomy has been performed successfully with laparoscopic methods, including pancreaticoduodenectomy for cancer. Shortly after the first descriptions of laparoscopic-assisted colectomy, reports of port-site tumor recurrences surfaced, raising concerns of using pneumoperitoneum-based surgery for malignancy. This review covers the development of laparoscopic surgery for cancer. Historical perspectives elucidate factors that helped shape the current state of the art. Theoretical concerns are discussed regarding surgery-induced immune suppression and its potential effects on tumor recurrence with both open and laparoscopic approaches. The concerns of laparoscopic port-site wound metastases are addressed, with a critical evaluation of the literature. Finally, a technical discussion of laparoscopic-assisted resections of hepatic and pancreatic tumors details patient selection, operative approach, and existing data for these operations.
With his article, Kooby has helped chaperone us through the history, research, and technical points of what is arguably the most important surgical innovation of our generation. As noted in the article, minimally invasive surgery has become the standard of care for many surgical conditions. However, the issue of how to best utilize this relatively new and evolving technique in the realm of solid organ malignancy still remains. It is this point that we wish to highlight, as it is our belief that we as surgeons and scientists must continue to push for innovative approaches and unique metrics to assure best practice for our patients. In light of this thought-provoking article I wish to develop the issues that Kooby has raised. We will focus on the importance of history, the resulting research, and education of surgeons regarding technique.
As Kooby's article suggests, the history of surgical innovation in laparoscopy is surprisingly long. The underlying question is why has it taken so long to adopt these techniques in practice? Of course the issues of oncologic equivalence and possible lack of training of staff surgeons, and thus residents, in "centers of excellence" have led to poor adoption until the late 1990s and early 21st century. However, what was it that prevented surgeons from adopting techniques that began what is now over 100 years ago? Why is it that in 2006, we have finally stepped through a door where these techniques are exploding in use and popularity?
As with all innovations in technology, there can be no underestimating the impact of key individuals or specific technologies in tipping the balance from individual use to widespread adoption. Echoing the phenomenon that Malcolm Gladwell explores in his best-selling book The Tipping Point, it is these people and events that resonate with the community at large and lead to advances in science and medicine. Examples of such individuals and innovations are given in this article but further context definition is needed. Kooby's example of "cold light" is a perfect illustration of a tipping point in history. In 1956, during one of the first joint physician-led research and development projects with industry, the first working flexible endoscope was created. We all know how that story ends, as this innovation has revolutionized modern medicine and surgery.
A second example is that of Eric Muhe. Although he was the first to perform a laparoscopic cholecystectomy, he is not credited with world-wide acceptance. Two years later, in 1987, Philippe Mouret became famous for this feat instead. It was Mouret's use of a "three-chip camera," which allowed his surgical team to view the procedure, that sent a wave of enthusiasm through the world that we still feel today. Other tipping points have occurred along the way; a recent example is the development of hand-assisted surgery. This innovation has shortened the learning curve and allowed surgeons of every generation to retool and join the momentum that minimally invasive surgery has created. However, a single resounding question remains: Do these innovations provide oncologic equivalence?
Research and Innovation
The theoretical effects of minimally invasive surgery are discussed in depth by Kooby, with an unbiased and careful review of the literature. As he notes, issues of oncologic equivalence and immune response have been the topics of the past decade. Although Kooby concludes that immune response "requires further study" and that the issues of port-site recurrence have been resolved in colon cancer by the randomized controlled trials COST, CLASSIC, and COLOR,[1-3] it is surprising that more is not said about the importance of such work to our patients. The ability to perform incredible technical feats such as laparoscopic colectomy, hepatectomy, and pancreatectomy are not as important as discovering whether such procedures are of benefit to patients. Luckily, we have historical models to follow, such as these trials in colorectal surgery.[1-3] Surgery for malignancy is not as simplistic a model as we find in cholecystectomy. In the cancer field, we are dealing with issues that extend beyond 30-day mortality and morbidity. Therefore, it is paramount that we develop ways to rigorously test these novel technologies to prove that they result in at least equivalent outcomes.
From our perspective it is important that leaders like Kooby and others involved in laparoscopic surgery for cancer engage in a process of discovery about such issues before it becomes too late. As highlighted by Kooby in Tables 4 and 5, little is known about the results of operations for hepatic or pancreatic malignancy outside of small single-institution studies.
The dilemma for all innovative surgeons is timing. Today the life cycle of technology is so short that there is an enormous need to develop novel ways to efficiently and rapidly address the research issues of oncologic outcomes. If we are unable to do so we will either be held hostage to the long, drawn-out process of traditional research or worse-proceed ahead with procedures and technologies that have the potential to negatively affect patients' lives.
The third topic of importance is technique and utilization of new technology in surgical practice. Kooby's detailed description of liver and pancreatic surgery should be commended as it accurately describes difficult and complex operations. In his conclusions Kooby states that minimally invasive surgery is "not for every patient, nor is it for every surgeon." Although I agree completely with this statement I would counter with the question why? Of course, there are many publications that consider the importance of training and volume in oncologic outcomes. There have been almost no data published on this subject in laparoscopic surgery.
Recently, the COST study group looked at this issue (unpublished work). Due to the nature of the COST trial, participants were all well-trained general, oncologic, and colorectal surgeons who were subjected to standardized credentialing. Regardless of the variable studied, all surgeons within the trial had similar oncologic outcomes. However, similar trials like CLASICC and COLOR[2,4] found a wide range of results, some strikingly poor. The issue of who should be doing these complex operations is one of extreme controversy with little data to support firm conclusions. Again, the simple ability to perform an operation does not constitute endorsement of the operation. Therefore, this issue is of paramount importance and will demand further study.
In this modern era filled with rapid change let us not forget the people who benefit or suffer from the choices we make. Let us instead take the innovative ideas and techniques of Kooby and others and incorporate them into quality research that defines the standards of practice for the future. The models for this dot the landscape of surgical history. Today there is no choice except to engage in the translational research of innovation and modern surgical practice.
-David W. Larson, MD
-Heidi Nelson, MD
The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
1. Clinical Outcomes of Surgical Therapy Study Group: A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 350:2050-2059, 2004.
2. Guillou PJ, Quirke P, Thorpe H, et al: Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): Multicentre, randomised controlled trial. Lancet 365:1718-1726, 2005.
3. Veldkamp R, Kuhry E, Hop WC, et al: Laparoscopic surgery versus open surgery for colon cancer: Short-term outcomes of a randomised trial. Lancet Oncol 6:477-484, 2005.
4. Kuhry E, Bonjer HJ, Haglind E, et al: Impact of hospital case volume on short-term outcome after laparoscopic operation for colonic cancer. Surg Endosc 19:687-692, 2005.
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