Laparoscopic Resection for Rectal Cancer

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 !