Hybrid Procedure Uses Both Laparoscopic and Open Surgery for Rectal Cancer

BOSTON—A hybrid approach mixing laparoscopic and open procedures in surgery for rectal cancer may allow patients a faster recovery, Richard L. Whelan, MD, said at the American Society of Colon and Rectal Surgeons annual meeting. The approach uses laparoscopic methods for splenic flexure takedown in the area near the diaphragm at the start of the operation and switches to open surgery for removal of the cancer from the rectum.

This combination can remove as much cancer as conventional surgery, but with a shorter incision and briefer hospital stay, according to a retrospective review of Dr. Whelan’s patients. In an interview with ONI, he described the review as “an interesting preliminary study” that will be followed shortly by a randomized trial.

“The whole point of doing the laparoscopic part is that it’s better to have a small incision than a larger one,” said Dr. Whelan, associate professor of surgery, Columbia Presbyterian Medical Center, New York. “If we can keep the incision below the umbilicus, I believe it will result in improved pulmonary function, greater ambulation, and shorter length of stay.”

The retrospective study compared outcomes for 31 patients who had the hybrid surgery in the last 3 to 6 years with outcomes for 25 patients who were operated on in a fully open procedure 8 to 9 years ago. “It’s not a randomized study or a concurrent one,” Dr. Whelan cautioned, calling it a good comparison nonetheless because one surgeon did all of the operations.

Neoplasm was diagnosed in 87% of the hybrid patients and 68% of those who had fully open surgery, with the majority of tumors located 4 cm to 10 cm from the dentate line. All the patients had splenic flexure takedown and rectal anastomosis. Low anterior or coloanal resections were done in 58% of the hybrid group and 68% of the fully open group.

Dr. Whelan and his co-authors found that the hybrid method cut the mean incision length by more than half: 11 cm vs 24 cm for the fully open group. The hybrid patients also made faster prog-ress by a day or two in resuming bowel movements and regular diets. Complication rates were similar, but the hybrid patients’ hospital stays were significantly shorter: 6.1 days vs 11.1 days for the fully open surgery patients.

“All that matters in the end is how the patient does,” said Dr. Whelan, emphasizing that the two procedures proved to be equally successful in removing the cancer. A comparison of specimens from hybrid and conventional surgery showed no difference in the distal margins, size, or lymph node status, he said.

While laparoscopic surgery is being tested in a number of clinical trials for colon cancer, it has been considered less promising for rectal cancers because of technical difficulties in working around the complex anatomy near the rectum. “Working down in the pelvis can be difficult,” Dr. Whelan acknowledged, explaining that the hybrid method allows a surgeon to remove the cancer manually using traditional methods.

Located in the left upper quadrant near the diaphragm, the splenic flexure usually must be mobilized in order to rejoin the remaining colon and rectum, he said. This can be done laparoscopically; otherwise, an extension of the incision above the umbilicus is needed. Upper abdominal incisions, more than lower ones, limit pulmonary function. The hybrid approach avoids the upper incision.

Dr. Whelan said that, in theory, there may be an oncologic benefit associated with avoidance of a long incision. Animal studies have shown that full-length abdominal incisions are associated with more rapid tumor growth and more metastases than laparoscopy. He stressed that the current human study neither addressed nor proved this theory.