Seminars in Surgical Oncology 10398-403 (194)

Laparoscopic Surgery for Colorectal Neoplasms

WAYNE L. AMBROZE, JR., MD. FACS, GUY R. ORANGIO, MD, FACS, DAVID ARMSTRONG, MD,

MARION SCHERTZER, MD, AND GEORGE LUCAS, MD, FACS

From the Georgia Baptist Medical Center, Atlanta, Georgia

Laparoscopy is being used to assist in an increasing number and variety of bowel procedures. However, when being used for neoplastic disease concerns of margins and adequacy of mesenteric dissection must be addressed. We’ve performed 1 10 laparoscopic-assisted bowel proce- dures, with 45 of these performed for neoplastic disease. Ninety-two bowel resections were performed including 24 subtotal, total, or proc- tocolectomies. In this chapter we review the results of our series, as well as other reported series, and discuss some of the controversies involved with laparoscopy for neoplastic disease. 0 1994 WiIey-Liss, Inc.

KEY WORDS: laparoscopy, resection, bowel, colon, cancer

INTRODUCTION During the 80 years following the first description of

laparoscopy by Ott in 1901, the technique received only limited acceptance and application in the main- stream surgical community [ 11. Problems of visualiza- tion and maneuverability for both the surgeon and assistants hampered its use outside a few diagnostic, and fewer still, therapeutic procedures. With the intro- duction of fiberoptics and, subsequently, videoendos- copy, imaging improved to the point that not only could common procedures such as cholecystectomy be performed using the laparoscope but laparoscopic cholecystectomy has rapidly become the standard of care [2-41. As increasing numbers of general surgeons became familiar with laparoscopic techniques and wit- nessed its advantages in terms of discomfort, scarring, hospitalization and short term morbidity in their cholecystectomy patients, it appeared reasonable to apply these techniques to other abdominal proce- dures, including bowel surgery [5- 131.

Many surgeons initial attempts at laparoscopic bowel surgery ended in frustration and in some cases, abandonment of the technique. There were many rea- sons for this frustration. In distinction to gallbladder surgery, bowel surgery requires dissection of large tis- sue planes as well as ligation of multiple large vessels. Also, as the procedure progresses along the bowel, the surgical field changes, requiring frequent time-con- suming adjustments in retraction and table position to

0 1994 Wiley-Liss, Inc.

obtain adequate visualization. With larger tissue specimens, larger incisions were needed for their re- moval. Also in distinction to cholecystectomy, an anastomosis must be performed. Finally when operat- ing on the bowel for malignancy, adequate cancer margins must be obtained.

In this chapter we will discuss the role to date of laparoscopy in diagnosing and treating colorectal neo- plasms. We will first discuss the techniques used in performing our initial 110 laparoscopic bowel proce- dures. We will then report the results of this series as well as review the results of other reported series. Fi- nally, we will try to put this information into perspec- tive with regard to applicability, safety, adequacy of resection, and future trends for laparoscopic bowel surgery.

MATERIALS AND METHODS The contraindications to laparoscopy are relative

and still not well defined. As a general rule we ex- cluded patients who were massively obese, had severe congestive heart failure or chronic obstructive pulmo- nary disease, as well as patients with large bulky le- sions or perforated malignancies. In massively obese patients, an extracorporeal anastomosis cannot be performed because despite full mobilization of the bowel, the bowel ends will not reach the skin level

Address reprint requests to W.L. Ambroze Jr., MD. 5555 Peach- tree Dunwoody Road, Suite 206, Atlanta, GA 30342.

Laparoscopy for Colorectal Neoplasms 399

without stripping the necessary adjacent blood supply. The pneumoperitoneum decreases venous return and cardiac output and as such should not be used in patients with a poor cardiac ejection fraction [14]. Pro- longed pneumoperitoneum will also cause mild hyper- carbia and should be avoided in patients who retain COz [ 151. Large or perforated malignancies should be avoided to prevent the risk of seeding tumor into the small wound from which it is extracted.

Our patients were given a full mechanical and anti- biotic preparation prior to surgery similar to that used in our open procedures. We avoided performing the preoperative colonoscopy the day of surgery to limit bowel distension. Venous compression hose were placed on patients prior to induction of general endo- tracheal anesthesia. A Foley catheter was placed in all patients, as was an oral-gastric tube. The oral-gastric tube was removed at the end of the procedure. Patients undergoing resection of the sigmoid colon or rectum were placed in the modified lithotomy position with the thighs raised only slightly to avoid interfering with the maneuverability of the instruments during the dis- section of the upper abdomen. All other patients were placed in the supine position.

All trocars were placed at or below the level of the umbilicus (Fig. 1). This is to further limit postopera- tive discomfort and facilitate postoperative pulmo- nary function. A Hassan trocar is placed in the umbiii- cus. A 10-mm port is placed in both the left lower quadrant and the right lower quadrant. A 12-mm port is substituted for one of the 10-mm ports if, as for all neoplasms, intracorporeal takedown of the mesentery is anticipated. This allows for passage of the endo- scopic linear vascular stapling device. Most right colon and sigmoid colon mobilizations can be per- formed with 3 ports. When more retraction is neces- sary, as is usually the case with splenic flexure and pelvic dissections, a fourth suprapubic port is intro- duced. All ports are 10 or 12 mm to allow for versatil- ity in placing instruments through each port.

An important facet of laparoscopic bowel surgery is to keep the procedure as simple as possible as well as limit the cost. An operating table full of equipment can be confusing and costly. Also every time an instru- ment is removed, changed, and reintroduced through the trocars, some CO2 is lost, changing the field of view slightly. Circulating nurses frequently going in and out of the operating room for new equipment, which may offer at best a small advantage for the task at hand, further adds to the confusion. When perform- ing a total proctocolectomy the only laparoscopic equipment necessary are the four ports mentioned ear- lier, two endoscopic clamps for traction, an endo- scopic scissor with cautery for dissection, and a suc-

Fig. 1. A Hassan trocar is placed in the umbilicus and both a right and left lower quadrant 10-mm trocar are used. No trocars were placed above the umbilicus.

tion-irrigation system. Vascular clips and staples were kept in the room but not opened unless needed.

When entering the abdomen full inspection is per- formed. The dissection is performed in a planned or- derly fashion. All adjacent structures such as ureters, vessels, and the duodenum are identified. An injury to adjacent bowel does not always necessitate open lapa- rotomy if the surgeon is comfortable with the endo- scopic repair of the enterotomy [ 161. We complete one area of dissection before repositioning to another, as obtaining traction and visualization is time-consum- ing.

The mesentery is managed in one of two ways, de- pending on the nature of the disease and the mobility of the dissected bowel segment to be removed. For benign disease the mesentery can be taken extracor- poreally between clamps, cut and ligated when the specimen is delivered through an enlarged trocar in- cision on the abdominal wall. When a specimen is not brought out through the abdominal wall but delivered through the transanal (Fig. 2) or tran- sperineal route, the mesentery must be taken in- tracorporeally to allow enough mobility to deliver the specimen. Also, for a cancer operation the mes- entery must be ligated intracorporeally. The vessels must be ligated at their origin, which is fixed posteri- orly, and such that no amount of dissection will bring the origin of the vessel to the anterior abdomi- nal wall. Dissection of the origin of the inferior mes- enteric artery at the aorta can be practiced using ei- ther the canine or swine model [5]. The named vessels such as the ileocolic, right colic, middle colic, left colic, or inferior mesenteric artery are transected at their origin using a single firing of the endoscopic linear vascular stapler (Fig. 3).

400 Ambroze et al.

Fig. 2. rectal carcinoma prior to transection and coloanal anastomosis.

Transanal delivery of proctocolectomy specimen for a low

Fig. 3. ligation of the inferior mesenteric artery for rectal carcinoma.

Sigmoid colon (left) and rectum with stapled (bottom)

The specimen is removed either through an enlarged trocar wound, usually enlarged to 4 cm, or via a tran- sanal (Fig. 3) or transperineal (with abdominal peri- neal resection) route. Large bulky tumors or perfora- ted tumors require larger incisions to remove the specimen to minimize manipulation and the possibil- ity of tumor seeding into the wound. For this reason we avoid laparoscopic-assisted surgery for these le- sions, as much of the benefit of this technique is lost with the larger incision.

The anastomosis, whether hand-sewn or stapled, is performed in one of three ways. If both ends of the resected specimen are brought to the abdominal wall,

Fig. 4. with coloanal anastomosis and temporary loop ileostomy.

Abdominal wall following laparoscopic proctocolectomy

an extra corporeal anastomosis is performed under direct vision. If the distal end of the specimen will not reach the abdominal wall, as with an anterior resec- tion, the distal resection line is transected using a 60- mm linear endoscopic stapler, the specimen is brought out through the enlarged left lower quadrant trocar site, transected, and the pursestring placed in the prox- imal bowel. The anvil of the intraluminal stapler is placed in the proximal bowel lumen and this is re- turned to the abdominal cavity. The wound is closed and then under laparoscopic vision a double stapled end-to-end anastomosis performed using the in- traluminal stapler which is passed up through the rec- tum. Finally for an ileal-anal or coloanal anastomosis, a hand-sewn transanal anastomosis is performed. Though Milson et al. describe a nice technique for an intracorporeal anastomosis in the swine model, we have found little application for this in humans as a small incision is necessary to remove the specimen, and the extracorporeal anastomosis can be done quickly under direct vision through this incision [17].

Finally, we close all incisions including the trocar sites. We use absorbable suture in the fascia as well as a running subcuticular closure of each wound. Oral liquids are started when flatus is passed, and if toler- ated, solids are started the following day. Patients are discharged when oral hydration can be maintained and the intravenous fluids discontinued.

OUR RESULTS Between November 1991 and December 1993 we

performed 1 10 laparoscopic-assisted bowel proce- dures. The patient population included 66 females and 44 males with a mean age of 48 years (range 10-95). Eleven patients were less than 18 years old, while 19 were greater than 70 years of age. Forty-seven patients (43%) had prior abdominal surgery; 66 patients (60%)

Laparoscopy for Colorectal Neoplasms 401

had other associated medical conditions with hyper- tension and mild chronic obstructive pulmonary dis- ease being the most common. The indications for sur- gery are listed in Table I, and included neoplastic disease in 45 patients. The neoplasms included 17 colon carcinomas, 9 rectal carcinomas, 1 colon leio- myosarcoma, 1 appendical carcinoid, 13 benign vil- lous tumors, and 4 patients with multiple polyps (two with familial adenomatous polyposis coli).

The procedures performed are listed in Table 11. While 16 procedures were done for fecal diversion (ileostomy or colostomy), 24 procedures were either subtotal, total, or total proctocolectomies, indicating the broad spectrum of bowel procedures which can be done with laparoscopic assistance.

We were able to complete 97 procedures (88%) laparoscopically without the need to convert to open laparotomy. Our average operating time was 140 min (range 20-420). We had one visceral injury, a partial transection of one ureter, treated without complica- tion using a temporary urinary stent. The average blood loss was 160 mm (range 10-700). The average total wound length including trocar sites was 6 cm (range 2- 12).

There was a total of 10 (9%) postoperative com- plications and no deaths. The complications included

TABLE I. LaparoscopicaUy Assisted Bowel Procedures: Indications for Surgery (n = 110)

Indications for surgery

Carcinoma Crohns disease Polypsipolyposis Ulcerative colitis Diverticular disease R-V fistula Incontinence Rectal prolapse Volvulus Inertia Endometrioma AV malformation

n

28 21 17 14 10 7 4 3 2 2 1 1

-

TABLE 11. Laparoscopic Bowel Procedures Performed (n = 110)

Procedure n

Right colectomy Sigmoid colectomy Stoma creation Proctocolectomyi J pouch Ileocolectom y Totalisubtotal colectomy Anterior resection Abdominoperineal resection Small bowel resectionistricturoplasty Left colectomy Colotomy

20 17 16 15 10 9 9 5 4 2 2

Hartmann takedown 1

two cases of gastric ileus treated with nasogastric tube intubation, one mesenteric bleed requiring laparot- omy, one perineal bleed requiring transperineal suture ligation of a bleeding vessel in the levator ani muscle, one anastomotic leak, one infected hematoma, one patient with urinary retention, one patient with uri- nary sepsis, one deep vein thrombosis, and one trocar site hernia.

Parameters followed postoperatively (Table 111) were the average day on which oral liquids and solids were started (day 3 and 4, respectively), the average postoperative day of discharge (4.6 days), and the av- erage date of return to work or 90% of preoperative activity (18 days).

RESULTS OF OTHER STUDIES In addition to our results reported here, there are a

number of other reported early series for laparoscopic bowel surgery, which we will summarize with respect to cost, safety, and efficacy of the procedure. In a series of 20 laparoscopically assisted colon resections, half of which were done for colon cancer, Quatt- lebaum et al. had no mortality with average return of gastrointestinal activity in 2.5 days and average hospi- tal stay of less than 5 days [18].

In a multicenter retrospective study Phillips et al. report the results of 51 laparoscopic bowel proce- dures. Their conversion rate to open laparotomy was 8%. Their average operative time was 2.3 hr, with average hospital stay of 4.6 days. The complication rate was 8% with one death (2% mortality) [19]. In another retrospective multicenter study, Senagore et al. compared 102 open procedures to 38 laparoscopic cases [20]. They found no significant difference in mor- bidity. Operative times in their study were increased for laparoscopic surgery, but blood loss, return of bowel function, and hospital cost were all decreased significantly for the laparoscopic group.

In another multicenter study by Falk et al., 66 laparoscopic colectomies were compared to a similar matched group of open colectomies [21]. Their conver- sion rate was 48% with morbidity rate of 24% and no mortality. They found that the lymph node harvest in the specimens from the laparoscopic cases was similar to the open cases. They also found that while hospital stays were significantly less for the laparoscopic cases, the hospital costs were similar.

TABLE 111. Laparoscopic Bowel Procedures: Postoperative Course

Days Range ____

Average day postoperative liquids stated 3 1-11 Average day PO solids started 4 2-12

Average day return to worki90% function 18 7-42 Average day of hospital discharge 4.6 1-14

402 Ambroze et al.

Finally, in a retrospective study by Peters et al. com- paring 28 laparoscopic colectomies to 33 open colecto- mies, they had a conversion rate to open colectomy of 14% with a morbidity and mortality of 13 and 3%, respectively. The operative time of the laparoscopic group was significantly longer while the hospital stay was significantly decreased. Again they found no sig- nificant difference in the lymph node harvest between the two groups.

DISCUSSION The mainstay of treatment of the 150,000 new cases

of colorectal carcinoma diagnosed in this country each year is surgical resection. Once suspected, the disease is usually easily diagnosed by colonoscopy. The role of diagnostic laparoscopy is discussed in another article in this journal. Since resection is generally recom- mended, even when metastatic disease is present for colorectal carcinoma, there is little role for diagnostic laparoscopy to avoid laparotomy. There may be a limited role for diagnostic laparoscopy if extensive metastatic disease is suspected with the intention of performing a laparoscopic diversionary procedure if extensive disease is found. Also, diagnostic laparos- copy might be indicated when recurrent extraluminal disease is suspected but cannot be demonstrated radi- ographically.

Therapeutic laparoscopy, including colotomy with polypectomy or segmental resection for benign co- lonic neoplastic disease, has been described in this as well as other articles [ 18-22]. While the advantages of using laparoscopy for these lesions appears obvious, its application is limited to those lesions which cannot be removed by intraluminal endoscopy or by local transanal excision.

For laparoscopy to have a significant role in the management of colorectal neoplastic disease, it will have to be applicable to the majority of colonic resec- tions, with adequate cancer margins and have a de- monstrable benefit over open laparotomy for the pa- tient. Our series, as well as those of others mentioned in this article, demonstrate that the entire spectrum of colonic procedures from simple diversionary stoma formation to total proctocolectomy with ileal-anal anastomosis can be done and done with morbidity and mortality similar to that of comparable open proce- dures. This is especially remarkable since all the laparoscopic series are at the beginning of the sur- geon’s learning curve and are being compared to open procedures identical to those which the individual sur- geons may have performed hundreds or thousands of times prior to those used in these series.

Surgical margins must be obtained, both on the bowel and along the mesentery. When operating for

proven or suspected carcinoma, the surgeon must first decide what operation needs to be performed, and then decide if this can be accomplished with laparo- scopic assistance. If not, then laparoscopy should not be attempted. If initially thought to be possible, but during the procedure the previously determined mar- gins are not obtainable for whatever reason, laparos- copy should be abandoned and the case converted to an open laparotomy. Scott et al. emphasized the im- portance of retrieving at least 13 lymph nodes in order to accurately identify metastatic disease [23]. The stud- ies by Falk and Peters confirmed similar lymph node retrieval for the laparoscopic cases compared to open cases [21, 221. This would be expected if a wide ana- tomic dissection as recommended by Enker et al. and Jarvinen et al. is performed [24, 251. We have ligated each of the named vessels to the colon and rectum intracorporeally. However, in some patients the vessel could not be isolated at its origin due to poor visual- ization and in these instances, when operating for ma- lignancy, the case was converted to open laparotomy.

Laparoscopic colon resection takes longer to per- form. This is because the procedure is technically more complex with less available options for visceral retrac- tion. So why as surgeons do we put ourselves through these gyrations? The answer of course is that we are looking to cure our patients with the least amount of discomfort, disability, and to some degree, scarring. The early studies seem to indicate that there is an advantage to the patients in terms of blood loss, early return of gastrointestinal function, and early dis- charge from the hospital as well as scarring and short- term disability. I think it is reasonable to presume that as the next generation of surgeons emerges who have begun their training during the “laparoscopic era,” as surgeons in general gain more experience with laparoscopy, and as technology continues to improve to meet the surgeons’ needs, we should continue to see improvement in terms of the magnitude and scope of procedures performed laparoscopically as well as im- proved results in terms of patient outcome.

ACKNOWLEDGMENTS

assistance in preparing this manuscript. I would like to acknowledge Deborah Miller for her

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