There is probably no other topic in the field of surgery that has generated so much controversy over the past 15 years than the use of laparoscopy for curative resection of colon and rectal cancer. There have been several prospective randomized studies that have absolutely taken the question mark out of the title of this article. Although I am a fellowship-trained colorectal surgeon, and thus biased toward my extensive training in laparoscopy, I can present both the pros and the cons for its use and let you decide.
Patient selection is critical when determining if someone would benefit from a laparoscopic resection. A cancer or other large mass can be safely removed without sacrificing negative tumor margins nor adequate lymph node yield from anywhere in the colon and proximal rectum as long as the tumor size is a T3 (i.e., no invasion into other organs or structures) or smaller as shown by CAT scan. Other criteria for laparoscopy include no evidence or perforation or obstruction.
Surgeon selection is equally important for the patient with a diagnosis of colon cancer. Laparoscopic colonic resection is considered to be an advanced technique that requires a steep learning curve of at least 25 procedures. Some general surgeons, especially those whose training did not include advanced laparoscopic techniques, have a difficult time adjusting and are thus more prone to surgical complications or tend to steer patients toward an open resection. Younger surgeons with specialized fellowship training such as advanced laparoscopy or colorectal surgery have obtained the skills and knowledge to perform these procedures with equal risk of morbidity and mortality as compared to an open resection.
The major concerns that were prominent when laparoscopic colorectal cancer resection was initiated, such as adequacy of oncologic resection, recurrence rates and patterns, and long-term survival have all been extensively studied and compared to open resection with no significant differences between the two techniques. In fact, a few studies have shown a slight advantage in long-term survival in patients who have undergone laparoscopic resection compared to same patient criteria who underwent open resection.
Besides a steep learning curve, there are two disadvantages to laparoscopic colorectal cancer resections: cost and longer operating room time. All three of these disadvantages overlap, and as a surgeon becomes proficient in the laparoscopic technique, the OR time will decrease to a time that is comparable to an open resection. While cutting OR time is a key money-saving method, the cost of laparoscopic tools will more than likely always keep the total OR cost of laparoscopy higher than that of an open resection.
The benefits to the patient, and thus the advantages of laparoscopy have been well documented. There is a significant reduction in post-operative pain and a decrease in the need for postoperative analgesia related to the smaller size of the incision. Postoperative ileus is also less of a problem, and accordingly, with smaller amounts of narcotics, patients are returning to their normal eating habits and activities at a quicker rate, and therefore, are actually discharged from the hospital on average one day earlier. The cost savings of a shorter hospital stay and less narcotic use outweighs the higher cost of the OR instruments. Better cosmesis is also an important factor, especially with younger women. A surgeon with advanced laparoscopic techniques can remove an entire colon and rectum with just a Pfannenstiel incision and three small trocar incisions!
The field of surgery is always evolving, and it is important for both patients and physicians to be aware of newer, studied techniques that will improve the well-being of our patients as a whole.
Craig Amshel, MD is a colorectal fellowship-trained surgeon at South Bay Hospital in Sun City Center and can be reached at 813-633-0081 or www.absolutesurg.com. He also performs general surgery and endoscopy and will be happy to answer any of your questions. References to the above article are available upon request.
