Laparoscopic Surgery for Cancer: Historical, Theoretical, and Technical Considerations

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.

Surgical therapy for solid tumors of the abdomen and retroperitoneum carries a history replete with dogma and folklore. Concerns of tumors spreading during surgery are often shared by patients and surgeons. Various measures have been devised to minimize contamination and dissemination of neoplastic cells during solid tumor surgery. Minimally invasive approaches to resection of solid tumors are growing exponentially. Along with these new approaches, new anxieties have been expressed regarding oncologic outcomes for these patients, as reports of port-site metastases and widespread tumor dissemination have surfaced.

Fueled by market interests and improvements in technical skills and instrumentation, potential applications for minimally invasive surgery exploded during the 1990s. Interestingly, centers of excellence for tumor surgery did not keep pace with the laparoscopy boom, primarily due to early reports of tumor dissemination and port-site metastases.[1-4] Associations were drawn between CO₂ pneumoperitoneum and wound recurrence, and progress stalled. Furthermore, oncologic surgical training was relatively devoid of instructors familiar with minimally invasive methods.

Results of several recent large retrospective series and prospective trials have allayed initial concerns that laparoscopic approaches result in inferior cancer outcome.[5-7] Graduating surgical residents are assisting with more advanced laparoscopic procedures, and momentum for minimally invasive techniques for cancer surgery has grown. This article reviews historical, theoretical, and technical aspects of laparoscopic resection of solid tumors.

Surgery and Cancer: Fact vs Myth

Before examining how laparoscopy impacts cancer outcome, it is necessary to review the associations of standard surgical therapy (ie, laparotomy) and malignancy. It is a common concern that surgery can promote tumor spread.[8] This view is shared both by laypersons and health-care professionals, and is supported by some animal and human data for primary and metastatic disease.

Animal data provide some fascinating examples. Partial hepatectomy can stimulate growth of experimentally delivered hepatic metastases. It is postulated that preexisting micrometastases in the remnant liver, which under normal circumstances remain relatively dormant, are subject to growth factors expressed during liver regeneration and are thus stimulated to multiply.[9-11]

Another example comes from the groundbreaking work of Judah Folkman. Circulating proteins (endostatin and angiostatin) produced by primary flank tumors (Lewis lung carcinoma) in mice, which suppress growth of lung metastases, were identified.[12] In this model, removal of the flank tumor results in growth of lung lesions, which can be reversed by administering exogenous, purified endostatin. While human trials have not confirmed these preclinical findings, the implications of these discoveries are dramatic for cancer surgery.

Human data are less conclusive on the topic of surgery and cancer recurrence. Most reports are retrospective and subject to many confounding variables. For example, a recent report on recurrence following surgical therapy for breast cancer showed that 27% of premenopausal women with node-positive disease experienced recurrence or progression within 10 months of surgery, which was significantly greater than in node-negative or postmenopausal women.[13] The authors of this report conclude that a sudden acceleration of the metastatic process by surgery could explain these risk dynamics.

Several mechanical aspects of operation, the most obvious being careless technique with inadequate tumor handling and incomplete resection, are implicated in promoting tumor growth and recurrence. Dissemination of tumor cells from the primary lesion via lymphovascular channels is associated with reduced survival in many tumor models.[14-16] Furthermore, intraoperative tumor manipulation can increase the number of circulating tumor cells in the bloodstream.[17] As such, several maneuvers have been described to minimize this occurrence. Vascular ligation prior to manipulation of tumor-bearing organs was first proposed in 1967 by Dr. Rupert Turnbull, with his description and retrospective reporting of the "no touch" technique.[18] Although prospective evidence does not support improvement in cancer outcome using the "no touch" technique for colorectal cancer,[19] recent reports recommend similar ideology for pancreatic cancer[18,20] and liver cancer.[21,22]

Other commonly used methods to minimize tumor recurrence include irrigating with sterile water to lyse potentially free-floating cancer cells in the peritoneal cavity, changing surgical instruments after each use to avoid cross contamination, and placing wound protectors for specimen extraction.[23] Table 1 lists several theories on how surgery may negatively influence cancer outcome, as well as measures suggested to improve outcome. Surgeons that routinely treat solid tumors of the abdomen use some or all of these techniques to limit tumor spread during operation, despite a lack of level I evidence supporting the benefit of such practices.

In addition to mechanical factors and circulating growth factors, alterations to the host immune system as a result of surgical stress are thought to negatively impact tumor recurrence. The associations between immune function, cancer, laparotomy, and laparoscopy are discussed later in this article.

History of Laparoscopy in Cancer Treatment

Georg Kelling first combined peritoneoscopy with pneumoperitoneum in dogs in 1901.[24] While his primary goal of raising intraperitoneal pressure to tamponade gastrointestinal hemorrhage (termed Lufttamponade) did not pan out, the means he employed marked the beginning of a new era in surgical history. Shortly thereafter, a Swedish surgeon, Hans Christian Jacobeus, reported an experience of laparoscopic and thoracoscopic evaluations in 72 humans.[25] Despite these achievements, growth of laparoscopy was slow during the next 75 years and often confined to diagnostic procedures. The greatest limitations were image quality and the need for the surgeon to hold the endoscope to his eye, leaving only one hand free to work and his assistants blind to his actions.

Several technologic advances were seen in the 1950s, such as the fiberglass "cold light," which limited heat production and provided brighter images, and the rod lens system, which eliminated the air interface and improved image quality further.[24] Shortly following these innovations, the first defined application of minimally invasive surgery for cancer appeared: lymphoma diagnosis and staging, which obviated laparotomy and shortened hospitalization and wound healing.[26]

From the 1960s through the 1980s it was the gynecologic surgeons who embraced laparoscopic methods. Touted as the "father of modern laparoscopy," Kurt Semm is credited with performance of the first minimally invasive appendectomy as well as the first minimally invasive hysterectomy, among several other accomplishments.[27] General surgeons were slow to employ this technology, and when they did it was usually for diagnosis and staging.[28-30]

Development of the charge-coupled device three-chip camera in 1985 made the greatest impact.[24] That same year, the first laparoscopic cholecystectomy was performed by Eric Muhe in Germany[25] and the possibilities were recognized. During the next decade, laparoscopic methodology was applied to practically every open abdominal procedure, including complex operations such as esophagectomy, hepatic trisegmentectomy, pancreaticoduodenectomy, and aortic aneurysm repair. While these particular procedures are still not routine, general surgery is forever changed.

The most noteworthy change in minimally invasive surgery for cancer came with the initial report of laparoscopic-assisted colectomy.[31] With approximately 150,000 cases of colorectal cancer diagnosed in the United States annually, many of which are potential operative candidates, general surgeons who observed the paradigm shift in approach to cholecystectomy were now faced with the decision of how far to take their new-found minimally invasive skills. This meant additional training, longer operative times, decreased productivity, and a new set of potential perioperative complications.

On the other hand, media hype and consumer enthusiasm for laparo-scopic-assisted colectomy were hard to ignore. Promises of rapid, painless recovery and experimental evidence suggesting that minimally invasive surgery imparts less surgical stress and immune suppression than conventional open surgery, potentially leading to better cancer outcome, required further evaluation.

Immune Function, Cancer, Laparotomy, and Laparoscopy

The link between the immune system and cancer was first proposed by Thomas in 1959, with the immune surveillance hypothesis.[32] In this model, malignant cells are thought to arise in the body with similar frequency to infection, and the immune system provides constant surveillance to recognize and eliminate these threats. Tumors are thought to develop when malignant cells find resistance or immune escape mechanisms. The complex pattern of cancer risk seen in patients with chronic immunodeficient states, such as those with the human immunodeficiency virus, further supports the notion that immune suppression permits enhanced tumorigenesis.[33]

Evidence of surgically induced immune suppression abounds in preclinical and clinical research. Observations into the effects of trauma and surgical stress on the growth of primary and metastatic tumors have been made since Tyzzer in 1913.[34] Experimental evidence suggests that surgical stress impairs immune function, potentially promoting tumor development.[35-37] Abdominal surgery may alter systemic immunity at multiple levels. Early immune changes with surgery include elevations in circulating acute phase reactants and depression in cellular immune responses. Later changes include reductions in lymphocyte and macrophage function, decreased natural killer (NK) cell activity, reduced lymphocyte and neutrophil chemotaxis, and impaired delayed-type hypersensitivity responses.[38]

Sufficient preclinical and clinical data exist to suggest that immune function is better preserved in minimally invasive surgery than in open surgical procedures. Serum levels of C-reactive peptide, interleukin (IL)-1β, and IL-6 are statistically higher during and following laparotomy as opposed to laparoscopy.[39,40] Circulating neutrophil counts are higher with open procedures; however, postoperative neutrophilic hypochloric acid production is reduced with laparotomy as compared to laparoscopy, suggesting impaired antimicrobial activity.[41] Other changes with open surgery include greater suppression of delayed-type sensitivity,[42,43] reduced CD4+/CD8+ ratio, and impaired CD4+ function.[44,45]

Natural killer cells are a subpopulation of leukocytes known to recognize and destroy a variety of tumor and virally infected cells in vitro.[46] Animal studies show that NK cells help limit tumor development and formation of metastases.[47] Furthermore, a higher level of NK cell activity following tumor excision is associated with better prognosis.[48] Laparotomy promotes stress-induced reduction in NK cell activity in humans for several days[49]; this altered immune surveillance is linked to outbreaks of dormant infections[50] and may influence tumor progression by similar mechanisms. Reduced NK cell number and function is seen with open surgery as compared to laparoscopic surgery.[51,52]

While systemic immune function is better preserved with laparoscopy, this may not be the case with intraperitoneal immunity. Direct drying effects of prolonged CO₂ exposure, as well as inhibitory effects on intraperitoneal macrophage tumor necrosis factor-alpha production, may induce a locoregional immune suppression.[53] Several groups advocate gasless laparoscopy with abdominal wall lifters or alternative insufflation gases, such as helium,[54,55] but CO₂ insufflation is still standard. One can infer from this information that the interactions of immunity, cancer, and operative approach are complex, and that further study is required to clarify the clinical benefit of immune marker fluctuations. Table 2 summarizes data gathered from several preclinical and human studies demonstrating fluctuations in systemic immunity with open and laparoscopic surgery.

Surgical Wound Recurrence and Cancer Survival

Wound tumor recurrence was first described in 1885, following exploration for pancreatic cancer.[56] This phenomenon is observed in 1% or less of all cancer laparotomies; however, wound metastases are associated with a 50% mortality within 6 months.[57] Authors often conclude from these observations that prevention of wound recurrence is an important principle of surgical therapy for malignant disease. While no one can argue that wound recurrence is a poor sign, it is seldom found as an isolated event and often heralds coexistence of other metastatic sites.[5] Thus, wound metastases may speak to the biologic aggressive behavior of a malignancy, rather than simple poor surgical technique.

Momentum for advanced applications of laparoscopic technique faltered with case reports of wound metastases following laparoscopic-assisted colectomy for cancer.[1,4] The proverbial "other shoe" dropped in 1994, when Berends published an intimidating report of 14 colon resections for cancer in which three patients (21%) developed early port-site wound recurrences.[3] Reports such as this caused many centers of excellence for cancer care to voice concern regarding laparoscopic approaches for solid tumor resection.[3] In turn, numerous preclinical and clinical studies were performed to evaluate this phenomenon. Table 3 provides a listing of mechanisms whereby laparoscopy may contribute to cancer progression.

A great limitation of animal studies is that they are usually performed amid artificial conditions. Investigators will combine tumor cell suspensions of artificially high cell counts with atypical operative conditions, such as persistent high-pressure CO₂ leakage.[58-60] It is not surprising that under conditions such as these, wound recurrence is often higher in the laparoscopy arms of these experiments. Another study that compares groups with peritoneal tumor suspensions containing lower cell counts shows no statistical difference in port-site recurrence between groups with pneumoperitoneum and sham laparotomy.[61] Furthermore, other groups demonstrate better tumor outcome with pneumoperitoneum-based surgery than with laparotomy, with regard to both tumor growth and proliferative indices.[62,63] While these studies are experimentally interesting and important, the ability to extrapolate conclusions from these conflicting reports to human outcomes is limited.

So what do existing human data demonstrate? After initial concerns of inferior cancer outcomes for minimally invasive tumor surgery, retrospective and prospective data mostly support laparoscopic techniques as equivalent or noninferior to traditional open methods, both with regard to wound recurrence[57,64,65] and cancer outcome.[6,7,66] One group performed a prospective, nonrandomized evaluation that permitted patients to choose open (n = 75) vs laparoscopic (n = 74) approaches for colon cancer. With mean follow-up of 49 months, they found similar recurrence rates of 1.3% (laparoscopy-assisted) vs 2.7% (open, P = .1), and similar survival rates of 89% (laparoscopy-assisted) vs 87% (open, P = .5).[67] A prospective randomized study with 208 (106 laparoscopy-assisted and 102 open) patients showed no disease-specific survival difference at 6 years for all patients.[66] Interestingly, a small survival benefit was demonstrated in the laparoscopic arm for the subset of patients with node-positive disease. Other studies have refuted the survival advantage for stage III patients.[6]

Ultimately, it was the Clinical Outcomes of Surgical Therapy (COST) trial that renewed general enthusiasm for minimally invasive approaches to solid tumor resection.[6] In this well-conducted landmark study, 872 patients were analyzed for recurrence and survival on an intention-to-treat analysis. With a mean follow-up of 52 months, recurrence rates (16 vs 18%, P = not significant [NS]) and survival (86% vs 85%, P = NS) were similar. Furthermore, there were only two port-site recurrences among the 435 patients (0.4%) with laparoscopy-assisted resections. It can be concluded from these studies that provided sound technique and patient selection are used, laparoscopy-assisted colectomy for cancer is acceptable practice.

The ultimate question concerning laparoscopy and cancer remains that of survival. Will the short-term benefits conferred to the immune system provide a global benefit for patients with cancer? While no randomized data to date demonstrate this, one prospective nonrandomized series of 109 colectomies for cancer showed a mild (12%, P = NS) overall survival benefit for the subset of patients with node-positive disease.[68] Another series of 415 patients showed a 13% survival benefit (P = NS) for stage III patients,[69] and other nonrandomized and retrospective series show similar results.[70,71] Unfortunately, limited patient numbers and technical standardization make conclusions of cancer outcome more difficult to analyze in other tumor types.

Specific Organ Resections

Fewer data concerning minimally invasive surgery in foregut tumor resections exist, due to fewer overall cases and the greater technical complexity often required in treating these tumors. The ensuing discussion will focus on laparoscopic resection of hepatic and pancreatic neoplasms. Attention will be drawn to patient selection, staging, and basic operative technique. Of note, surgeons performing these procedures must be facile with hepatobiliary and pancreatic surgery as well as advanced minimally invasive surgery techniques. Other components for success in minimally invasive resections of the liver and pancreas include a consistent, knowledgeable operative team, preset instrument trays, laparoscopic ultrasonography equipment, endoscopic staplers, devices for parenchymal transection, and the availability of fibrin-based sealants.

Hand-Assisted Laparoscopic Surgery

Many surgeons prefer to incorporate a hand port when performing these advanced procedures. This is known as hand-assisted laparoscopic surgery (HALS) or "handoscopy." There are several benefits of HALS. First, improved retraction and degrees of freedom may shorten operative time and improve safety. Should hemorrhage become problematic, the surgeon can apply digital pressure. Should the case need to be converted to an open procedure quickly, the small preexisting wound can be extended rapidly. Currently, no laparoscopic instrument can compare to the surgeon's hand for retraction. Reincorporation of tactile feedback, which remains vital in tumor surgery, allows the surgeon to feel for peritoneal studding, or small hepatic surface nodules that are missed with ultrasonography. Finding an additional lesion may change operative management dramatically. Finally, the hand port incision can be limited to less than 7 cm, and specimen extraction ultimately requires a 5- to 7-cm incision in most cases.

Partial Hepatectomy

The first reports of minimally invasive hepatectomy appeared in 1991, shortly after the first laparoscopic-assisted colon resections.[72] These procedures were, appropriately, diagnostic for anterior, benign-appearing lesions identified incidentally during laparoscopy for other procedures. While minimally invasive cholecystectomy was rapidly gaining momentum, enthusiasm for laparoscopic liver resections was guarded due to concerns of blood loss, CO₂ gas embolism, and cancer recurrence. Improvements in laparoscopic ultrasonography, hand ports, and devices for parenchymal transection fostered renewed interest, and now minimally invasive hepatic resections are performed routinely in several high-volume centers worldwide.

The ideal patients are those with solitary tumors situated in the left lateral sector (segments 2 and 3) or segments 5 and 6 of the right liver. Although usually technically more demanding, right-sided laparoscopic resections are more likely to provide a significant recovery benefit over the traditional open approach, since the latter requires large muscle-cutting incisions to mobilize the right liver for safe access to the tumor. Usual preoperative screening is employed. For patients with metastatic colorectal cancer, computed tomography scanning (with or without positron-emission tomography scanning) is crucial. Repeat colonoscopy should be considered if it has been more than 6 months since prior evaluation, to avoid missing metachronous lesions, and patients over 65 years of age or with any predisposing risk factors should have cardiac evaluations. Other considerations include somatostatin-receptor (octreotide) scanning for hepatic neuroendocrine tumors, evaluating hepatoma patients for cirrhosis, and drawing appropriate tumor markers to follow for subsequent recurrence.

Left-sided lesions are best handled in lithotomy or on a special "split-leg table" to allow the surgeon to stand between the patient's legs for maximum comfort. Patient positioning for right-sided lesions is in semi-left lateral decubitus on a beanbag with an arm sling (Figure 1). It is imperative to secure the patient to the table, as intraoperative table movement is useful for exposure and gravity-assisted retraction. The hand port can be placed at the start and insufflation can be administered via a port placed in the gel. Similarly, palpation and ultrasonography can be performed through this solitary port.The goal of ultrasonographic evaluation is analysis of tumor number and location, with close attention to the proximity of hepatic vasculature and biliary structures. Once resectability is confirmed, the right liver is adequately mobilized and a planned line of transection is marked with electrocautery.

As with open resections, low central venous pressure anesthetic technique[73] with intermittent hepatic inflow occlusion (Pringle maneuver)[74] is employed to reduce blood loss during parenchymal transection. Precaution is taken to avoid inadvertent injury to major hepatic veins, as concerns of CO₂ gas embolism under pneumoperitoneum have been expressed. Several groups advocate minimizing insufflation pressures to reduce this risk.[75-77] Fortunately, existing series have not demonstrated increased incidence of this potentially lethal intraoperative event.

Parenchymal transection is performed along the designated transection line using an ultrasonic dissector and vascular staplers. Knowledge of the inflow and outflow by careful analysis of preoperative imaging, liver topography, and ultrasonography takes the guesswork out of the equation, and allows for safe, expedient progress. At the conclusion of transection, the specimen is set aside and the cut liver surface is examined for hemorrhage and bile leaks. An argon-beam coagulator and fibrin sealant or clotting matrix is used as necessary. Sutures are infrequently necessary, but can be applied using endoscopic needle holders. Once the liver surface is hemostatic, the specimen is easily removed through the hand port wound protector. If the specimen is too large and the incision needs to be extended, the specimen can be inserted in a laparoscopic sac and withdrawn without dragging it along the wound edges (Figure 2A). We prefer to close our 12-mm port sites irrespective of location, to limit inadvertent gas flow and "sloshing" through port sites. Complete desufflation of the abdomen is easily achieved by removal of the gel cap on the hand port, with the wound protector in place. Drains are not usually employed.

Postoperative management is the same as for open procedures. However, in our experience, HALS partial right hepatectomy patients are usually ready for discharge in 2 or 3 days, with less pain medication requirements. Postoperative scar appearance is demonstrated in Figure 2B. Other groups are beginning to report on lobar and extended lobar resections.[78] These are more feasible given familiarity with intrahepatic pedicle ligation, but require larger incisions for specimen extraction and are not yet commonplace. Results of published reports on partial hepatic resection for cancer are provided in Table 4.

Distal Pancreatectomy

Initial reports of minimally invasive distal pancreatectomy surfaced in 1993. This was followed by a report of laparoscopy-assisted pancreaticoduodenectomy in 1994,[79] which is not being recommended in this or any other written commentary to the author's knowledge. Other reports of tumor enucleation by laparoscopic methods have also been reported.[30] Our discussion will focus on the most common resection, which is distal or left pancreatectomy with en bloc splenectomy for cystic neoplasms of the pancreatic body or tail.

Similar to minimally invasive partial hepatectomy, patients should be in good physical condition and staged with CT scanning. In the majority of cases, patients will have cystic neoplasms with concerns of malignant potential (macrocystic appearance, solid components, septations, etc) or neuroendocrine tumors. Patients with obvious adenocarcinoma with extrapancreatic extension should not be considered for HALS pancreatectomy. Spleen-sparing minimally invasive left pancreatectomy is also possible.

Positioning is opposite to that of partial right hepatic resections in semi-right lateral decubitus. Hand ports are placed in the midline, halfway between the xiphoid process and the umbilicus. Two 12-mm ports are place in the left subcostal region (Figure 3A). We find this ideal to be able to switch transection device and camera with ease. An additional 5-mm port can be placed in the lateral position to aid in splenic retraction during division of the short gastric vessels, if necessary.

After inspection and palpation, the lesser sac is opened using the harmonic scalpel. The short gastric vessels are taken all the way up to the superior pole of the spleen and left diaphragmatic crus. The retrogastric adhesions are divided and the body and tail of the pancreas are thus exposed. The tumor should be visible at this point. The next move is to drop the distal transverse colon from the lower splenic pole. Care must be taken not to injure the colon or spleen at this point, and the hand assist is superb for this maneuver. Medialization of the spleen and pancreatic tail is performed and aided by gravity and hand retraction. Caution must be exercised with respect to the left renal vasculature and the left adrenal gland. Pancreatic body mobilization continues until the surgeon is confident he or she is well past the neoplasm. For proximal body tumors, the inferior mesenteric vein should be identified and transected with either the harmonic scalpel or a vascular endoscopic stapling device. The superior mesenteric vein and artery and the portal vein must be protected.

Once the pancreas has been adequately mobilized, the splenic artery is dissected free of the parenchyma with a Maryland dissector and divided proximal to the mass with a vascular endoscopic stapler. Similarly, the splenic vein is isolated and divided. The parenchyma can be transected in a variety of ways with endoscopic staplers, TA staplers, or sharp transection with suturing. Examples of an operative specimen and postoperative patient appearance are provided in Figures 3B and 3C. Drains are still routinely employed by the author for left-sided pancreatic resections.

Postoperative management is no different from open procedures, and drain amylase is evaluated after the patient is started on a diet. Table 5provides a list of existing distal or left pancreatic resections for solid and cystic neoplasms of the pancreatic body and tail.

Other Resections

The author has experience with a variety of other minimally invasive resections for neoplasms, including adrenalectomy, partial gastrectomy, retroperitoneal sarcoma, colectomy and proctectomy, and splenectomy. Approaches to these procedures are individualized and staging and cancer management are according to the same indications as open cases.

Conclusions

Minimally invasive surgical resection for neoplasms of the abdomen and retroperitoneum is not for every patient, nor is it for every surgeon. Routine staging and preoperative clearance are mandatory; a clear description of the procedure and realistic expectations must be conveyed to the patient, referring doctor, and operative team. Anesthesia colleagues must be reminded that despite smaller incisions, these are still major organ resections and invasive monitoring should be employed as necessary. Furthermore, with the patient in the lateral position, placement of arterial lines and central venous access is more challenging and should be considered before the patient is positioned.

Currently, the laparoscopic approach cannot be touted as a way to improve cancer outcome and limit tumor recurrence. More data are necessary to determine if the reduced immune suppression is clinically relevant, and the minimally invasive surgery approach is simply another way of getting the same thing done with smaller incisions. Multicenter trials like the COST trial for colon resections will help determine if a true benefit exists. The age of advanced laparoscopy for cancer is here, and provided surgeons and patients are realistic about outcomes and expectations, enough evidence exists to suggest it is reasonable to proceed.

Disclosures:

The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

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