Role of Laparoscopic Techniques in Colorectal Cancer Surgery

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.

Introduction

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 Surgery

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 colon.

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.

Clinical Trial of Laparoscopic vs Conventional Bowel Surgery

We are currently performing such a trial, which compares laparoscopic vs conventional bowel resection in certain cancer patients who require either a right colectomy, proctosigmoidectomy, or abdominoperineal resection. These procedures can generally be performed through five or six 5- to 12-mm abdominal wall incisions, as opposed to the long midline incision used in conventional surgery, which generally runs from the umbilicus to the symphysis pubis in length (Figure 2).

Prior to beginning this clinical trial, we worked extensively on animal and cadaver models to prove the anatomical feasibility of performing acceptable laparoscopic oncologic resection of the bowel [10-14]. In our animal studies, we showed the feasibility of performing a laparoscopic operation that includes proximal ligation of the vasculature supplying the right colon-a concept long held to be important in oncologic colon surgery.

In our opinion, there are definable operative criteria that may verify that an adequate oncologic resection has been performed relative to the anatomic extent of the resection. After performing a series of laparoscopic right colectomies, proctosigmoidectomies, abdominoperineal resections, and total abdominal colectomies in fresh cadavers, we evaluated the anatomical extent of resection via postprocedure autopsies [13,14]. The length of the remaining mesenteric vessels was measured, the number of remaining lymph nodes counted, and the overall extent of mesenteric and pelvic resection assessed. We concluded from these phase I studies that, by using a standardized approach (which we now duplicate successfully in patients), we could anatomically accomplish an oncologic resection that encompassed a high ligation of the major mesenteric vessels, with wide excision of the large intestine and its mesentery.

In our current phase 2 clinical cancer trial, all operative procedures are performed in accordance with established principles of oncologic surgery. These principles include: (1) proximal ligation of lymphatic-vascular structures; (2) prevention of intraluminal cancer spread; (3) wide en bloc resection of tumor-bearing tissue; (4) isolation of the tumor from surrounding tissue; and (5) creation of a safe anastomosis (!-Figure 3).

The purpose of this clinical trial is to compare morbidity, mortality, speed of recovery, and quality of life between laparoscopic and conventional colorectal cancer surgery patients. We believe that only if clinically relevant short-term advantages can be demonstrated after laparoscopic colorectal cancer surgery (compared to conventional surgery) should a phase 3 study be undertaken.

In such a phase 3 study, the long-term oncologic end points, recurrence and survival, must be evaluated in large numbers of patients at multiple sites, and at least equivalency between laparoscopic and conventional surgery should be demonstrated. Only after a thorough evaluation through all three clinical trial phases should laparoscopic surgery be widely recommended as a standard, proven treatment for colorectal cancer.

Why the Need for a Cautious Approach?

There are several reasons for such a cautious approach to assessing the value of laparoscopic techniques in curative colorectal cancer surgery. First, it is a new technique with unknown morbidity, mortality, and long-term results. Second, laparoscopic colorectal cancer surgery is technically more challenging, more time consuming, and more expensive than conventional surgery. Finally, an unusual and worrisome complication--early cannula site recurrence--has been reported after curative laparoscopic cancer surgery [15].

Early Cannula Site Recurrence--Such local recurrences in cannula sites, occurring as early as 1 week after initial curative resection, evoke major concern about the application of laparoscopy to cancer surgery. Nduka et al [16] conducted an extensive literature search and found 18 cases of cannula site recurrence after laparoscopic surgery for a variety of malignancies, the first of which was reported in 1978. Of these cases, 10 were reported in 1993, and the time between surgery and wound metastasis varied from 7 days to 10 months.

These authors theorize that the mechanism for implantation of viable tumor cells may relate to increased cell exfoliation with laparoscopic surgical manipulation, repeated contact between contaminated instruments and port sites, and passage of tissue through an unprotected incision. Such tumor-seeding is likely related to technique, and may be minimized using a standardized oncologic approach that encompasses the principles listed above.

The following precautions may also minimize tumor-seeding: (1) minimal manipulation of the tumor-bearing segment; (2) occlusion of the proximal and distal ends of the intestinal segment; (3) placement of the specimen, as soon as possible, into an impermeable endoscopic bag before delivery through the abdominal wall. This last step effectively isolates the tumor-bearing bowel segment from the abdominal cavity and from the abdominal incision through which the segment is removed.

In addition, every laparoscopic curative cancer resection we perform is documented on videotape, giving concrete evidence that the resection was done in accordance with these oncologic principles. The results of specimen processing by pathology also provide evidence of the adequacy of resection.

Assessing Possible Metastases--In conventional surgery, most surgeons palpate the liver, porta hepatis, and para-aortic tissues to clinically stage a colorectal tumor prior to resection. The inability to perform such palpation in laparoscopic cancer surgery is a concern, since metastases may exist in diverse locations within the abdominal cavity. Thus, such palpation must be replaced with other methods of assessing possible metastases. For this reason, all of our cancer patients undergo preoperative CT scanning of the abdomen and pelvis, utilizing intravascular and intraluminal contrast enhancement of the abdominal viscera.

We are also assessing the utility of intraoperative laparoscopic ultrasonography in scanning the liver. Intraoperative ultrasonography is a highly sensitive, quick, and inexpensive method of detecting hepatic lesions [17-21], which can be accomplished laparoscopically using a specialized probe. It has the potential to assess lymphatic tissue in the mesentery and to evaluate local tumor infiltration. We have demonstrated the feasibility of performing intraoperative laparoscopic ultrasound of the liver, and are using it as a part of the curative laparoscopic colorectal surgery procedure. The accuracy of laparoscopic ultrasonography compared with preoperative contrast-enhanced CT scan of the liver is currently under investigation at our institution (Cleveland Clinic Foundation RPC# 0008).

Contraindications to Laparoscopic Colorectal Cancer Resection

We believe that there are three main contraindications to resecting colorectal cancer laparoscopically: (1) tumors that have infiltrated into adjacent organs; (2) low or mid-rectal cancers that necessitate a low colorectal anastomosis; and (3) very large, bulky, or obstructing tumors.

Because of the current inability to manage an en bloc multivisceral resection laparoscopically, infiltration of adjacent structures by a malignancy is probably an indication for conversion to an open procedure. As an exception to this general rule, we have successfully performed laparoscopic resection of rectal cancers adherent to the vagina, in combination with perineal surgery.

Because of current laparoscopic instrumentation, rectal cancers that require a colorectal anastomosis deep in the pelvis cannot be resected laparoscopically. If articulating types of endoscopic staplers become available in the future, laparoscopic low anterior resections with colorectal anastomosis may become appropriate.

Difficulty controlling a large mass in the peritoneal cavity precludes laparoscopic resection of any tumor larger than 6 to 8 cm in diameter. In any event, such a lesion would require a long abdominal incision for complete and safe en bloc removal. Thus, conventional laparotomy should be the first choice for removing large tumors. Obstructing tumors tend to create bowel distention, which may impair overall visualization and prevent adequate exposure of the mesentery for laparoscopic resection.

Other Important Issues

Education--Laparoscopic colorectal surgery appears to be much more difficult to perform than laparoscopic cholecystectomy and, as a result, generally takes longer to learn. As yet, no formal educational programs have been established for laparoscopic colorectal surgery. The Society of American Gastrointestinal Surgeons (SAGES) has published general recommendations regarding this type of advanced surgical training [22]. However, specific standards for laparoscopic colorectal surgery have not yet been formulated.

At our institution, we follow a three-tiered educational program to train the members of our laparoscopic surgical team: First, basic laparoscopic colorectal surgical skills are acquired in inanimate models. Colorectal surgical techniques are then learned and practiced in animal models [23]. Finally, an experienced preceptor assists the surgeon in performing laparoscopic colorectal surgery in patients.

We have found that a unified team effort is especially helpful in facilitating a smooth laparoscopic operation. Such a skilled team helps to maximize effort and outcome, while decreasing overall operating room time. The latter is especially relevant for laparoscopic operations, which usually have somewhat longer operative times than traditional open surgical procedures.

Cost--The increased operating room cost associated with laparoscopic intervention is a byproduct of longer operating room time and the use of delicate, often disposable instruments. As surgeons and their operating room teams become more proficient in the performance of laparoscopic operations, the cost of laparoscopic colorectal intervention should approach that of its traditional counterparts. In addition, the results of randomized clinical trials may show that patients undergoing laparoscopic colorectal intervention have an easier postoperative course, including faster hospital discharge, which may actually decrease the cost associated with laparoscopic intervention.

Summary

There are currently a variety of large intestinal conditions for which laparoscopic techniques seem reasonable. Diagnostic procedures, the creation of intestinal stomas, and the performance of palliative resections may represent specific procedures in colorectal cancer patients that, when performed laparoscopically, may allow patients to recover more quickly and with less pain and smaller incisions compared to conventional surgery.

The role of laparoscopic techniques in curative colorectal cancer surgery is less clear. The difficulty of performing radical cancer surgery laparoscopically, coupled with the concern that recurrence rates are unknown and short-term advantages are unproven, lead us to believe that this surgery belongs, for the present, within the confines of institutionally approved clinical trials.

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