Post on 11-Nov-2014
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Laparoscopic colectomy 1st attempted in early 90’s
Slow to gain acceptance unlike rapid take-up of lap cholecystectomy
Reasons for this include:› Steep learning curve› Cost› Time› Concern re oncological soundness› Possible port site metastases
Sharp dissection between the parietal and visceral layers of the endopelvic fascia
Complete excision of rectum & draining lymphatics with intact visceral envelope
Preservation of pelvic autonomics Low local recurrence rates (4% @
10yrs) Heald 1986
Less blood loss Faster recovery Earlier return of gut function Lower morbidity Magnified view allows precise
dissection (pelvic autonomics)
Reduced pain Improved cosmesis Decreased adhesions Decreased wound infection rate Reduced immune effect of surgery
Steep learning curve Longer operating times (+30% to 50%) Cost
› Instruments / equipment Port-site recurrence? Oncological soundness compared with
open TME?
Practical and technical limitations › Crowding of instruments in the pelvis› Plume can obscure vision› Retraction of the rectum can be very
difficult› Division of the rectum can be difficult› Identification of tumour site can be difficult› Pneumoperitoneum
Gas embolism / decreased venous return
Purely Laparoscopic› Specimen extraction through natural orifice (ie anus)› Hand-sewn colo-anal anastomosis› No abdominal incision apart from port sites
Laparoscopically Assisted› Small incision for specimen retrieval
Hybrid› Incision to allow rectal dissection, vessel ligation or
anastomosis to be performed in an open fashion Hand-assisted Laparoscopy
› Combination of both open and laparoscopic techniques through a hand port
Optics / image Processing Energy devices (e.g. harmonic scalpel,
bipolar energy) New staplers Wound protectors / retractors Hand assist devices Robotics?
•Smaller, better optical properties•Magnification 15-20X•Flexible
Modified lithotomy (adjustable stirrups) Bean bag or soft mouldable mattress to
allow maximum tilt 4-5 cannulas (1/quadrant) CO2 insufflation (12-15mmHg) 30 degree or flexible laparoscope Laparoscope lens cleaner Plume extractor
IncisionIncisionIncisionIncision
May expedite the mid and upper abdominal steps May expedite the mid and upper abdominal steps
Pre-operative assessment› Can / should it be done
laparoscopically? Lateral to medial dissection Full mobilisation of splenic flexure High vascular division Rectal dissection / division /
anastomosis
Evidence is mainly from comparative non randomised trials
Many with small numbers & short follow-up
Two randomised trials in the literature looking at lap TME (restorative)› (Zhou 2004)› MRC CLASICC (Guillou 2005)
One RCT on Lap APR› (Araujo 2003)
Zhou et al (China) Extraperitoneal rectal cancer Lap : open = 82:89 No defunctioning ileostomy Short term results only No conversion rate reported
LapOpen
Mortality (%) 0 0 Morbidity (%) 6.1 12.4 Leak (%) 1.2 3.4 Operation time (min) 120 106 Blood loss (ml) 20 106 Pain (days) 3.9 4.1 First bowel action (days) 4.3 4.5 LOS (days) 8.1 13.3 (p=0.001)
Guillou et al (UK) Multicentre RCT Colon & rectal cancer All surgeons had performed at least 20
laparoscopic resections 794 patients randomized 2:1 for
laparoscopic : open surgery 381 patients with rectal cancer (253:128)
Lancet 2005 365:1718-26
Conversion 34% (overall fall in conversion rate during the trial)
Mortality - all patients (colon and rectal)› Intention to treat
Open 5% Lap 4%
› Actual treatment Open 5% Lap 1% Conversion 9%
Lancet 2005 365:1718-26
Complications – rectal cancer› Intention to treat
Open 37% Lap 40%
› Actual treatment Open 37% Lap 32% Conversion 59%
(p=0.002)
Open Lap Conv
Anaesthetic time* 135 180 180mins
1st BM 6 5 6days
Normal diet 7 6 7 days LOS 13 10 13 days
*Rectal and colonic resection
Cost – intention to treat (mean)
Open Lap Theatre £ 1448 £ 1816 Hospital £ 3713 £ 3359 Others £ 2659 £ 3085
Total £ 7820 £ 8260
Br J Cancer 2006 95:6-12
Quality of Life› no difference at 2 or 3 months
Good quality pathological specimens were received in both groups › (nodes and length to vascular tie)
Positive CRM rate (anterior resections)› Laparoscopic 12% (16/129)› Open 6% (4/64)
CLASSIC group suggest that laparoscopic anterior resection is not justified as a routinue approach due to concerns over:› Increased positive CRM rate› High morbidity with conversion
Learning curve underestimated at the 20 cases used in the trial
Araujo et al (Brazil) 28 patients – laparoscopic vs open APR Results
› No conversions› Operating time faster in laparoscopic group !
228 vs 284 mins (p=0.04)
› At mean 4yr follow up 0 recurrences in laparoscopic group 2 local recurrences in open group
Rev Hosp Clin Fac Med Sao Paulo 2003 58:133-40
Breukink et al (2006) 48 studies, 4244 patients Poor study methodologies, only 3 RCT’s No strong conclusions possible
5-year disease free survival› No apparent difference
Local Recurrence› Most studies found no significant difference› Overall <10% (variable follow up)› Higher for APR (0% - 25%)› 0% to 6% for sphincter-saving lap TME› Comparable to open situation (Heald
showed 33% LR after APR)
Perioperative mortality› No significant difference
Morbidity› No apparent difference› Trend towards lower complications in lap
groups Anastomotic leak
› No difference
Blood loss› Reduced with lap TME
Operative Time› Significantly longer with lap TME
Conversion Rate› Highly variable (0 to 33%)› Surgeon experience crucial
Surgical margins› No difference
Lymph node harvest› No difference
Postoperative recovery› Improved with lap TME
Quality of life› Insufficient data
Cost› Probably increased for lap TME› Poor data
Immune response to surgery› Appears reduced with lap TME
No firm conclusions Laparoscopic TME appears to have
short term benefits Long term oncological safety requires
further randomized trials
Port-site herniae› Rare at 0.3%› Attention to port site closure
Port site metastases› First reported 1993› Rare at 0.1% overall› Comparable to wound recurrence in open
surgery
Bladder and sexual function› Quah (Singapore)
80 patients randomised to open or laparoscopic assisted resection
Of sexually active males 46% (7/15) decreased function in laparoscopic group vs 6% (1/15) open
› CLASICC Erectile dysfunction in 41% of laparoscopic vs
23% open (NS)
Br J Surg 2002: 89:1551–6
Br J Surg 2005: 92:1124-32
Laparoscopic TME is technically challenging
In experienced hands, lap TME can be performed safely and confers short term post-operative benefits in terms of recovery
Cost and quality of life data are lacking
Long term oncological outcomes are unknown, but should be theoretically no worse if TME principles are followed
The 3 and 5-year results from the CLASSIC trial are awaited !