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To our patients suffering from cancer:May new scientific discoveries, improved treatments and technologies contribute to a better quality of life.
To my grandmother Margarethe Matteotti, my father Werner and Marythe greatest supporters in my life.
We would like to express a special thank you toStephanie Benko and Gabriele Schroederfrom Springer Verlag who greatly supported this project along the way.
The view of a pioneer in open approaches to Surgical Oncology
It must seem surprising that an ‘open surgery’ surgical dinosaur should be invited to write a foreword for this text on minimally invasive surgical oncology. I accepted with some trepidation, expecting to be faced with the unpleasant task of writing a critical foreword of a technical text. But the title misled me, this is not a technical treatise but a disease focused management text in which the technical issues of mini-mally invasive approaches are emphasized.
Above all, the text is comprehensive; from history to surgical education, research, robotics, to immunological response. Organ specific summaries are all covered in great depth. The authorship is a ‘who’s who’s’ of minimally invasive surgery and perhaps more importantly, a ‘who will be a who’, as the next generation develops these technical refinements. For me trying so long to focus on cancer management as a disease-based entity rather than a discipline-based entity it is most encouraging to see a text emphasizing technique but not neglecting important issues of underlying biology, evaluation and a synthesized approach to management. Having started my surgical career prior to the use of CT or MRI, I reflect how seamlessly we incorpo-rated these techniques into patient management. I am encouraged that this will be similarly encompassed by the current generation of surgical oncologists.
The trend is clear. They are courageous enough to address natural orifice surgery in oncology. Except for the increasing use of cesarean section as opposed to trans-vaginal delivery surgical procedures are progressively moving from large incisions to small incisions to natural orifice surgery. While debate will no doubt continue as to the relative importance of minimally invasive approaches over the more open approaches, it is clear to me that where applicable the avoidance of a large abdominal incision with its accompanying significant risk of subsequent incisional hernia, should be replaced with a minimally invasive approach. Whether the relevant merits of mini-mally invasive surgery change other issues of outcome should not be a debate. Minimally invasive surgery is a technique; it does not change the disease and one would hope would not change the discipline with which surgeons approach the appro-priate operation regardless of the technique employed. This then makes it an onco-logic text that allows support for a minimally invasive approach where appropriate.
It is not surprising that the minimally invasive approach has not been extensively embraced in technically challenging procedures particularly those that require not only resection but subsequent reconstruction. In situations where the techniques by which tumors are removed, for example pancreaticoduodenectomy, is less of an issue than the consequences of the reconstruction; it is no surprise that minimally invasive
viii Foreword I
approaches have not been embraced. Indeed, the choice of the minimally invasive approach in pancreatic surgery chooses the cases that are most amendable to success regardless of technical approach. We would all like to approach the “easy” case regardless of technique. Where minimally invasive approaches have most appeal is in the more challenging case, in the more challenging patient where the ability to per-form by a minimally invasive approach has very significant benefits to the patient. An obvious example of this is in hysterectomy and bilateral salpingo oophorectomy in the morbidly obese where morbidity of the resection is often associated with the extensive abdominal incision when approached conventionally. Some MIS approaches still appear to me to be techniques looking for an indication. When asked how mini-mally invasive surgery has altered my approach to thyroid and parathyroid surgery, I do confess my incision is smaller and the patient goes home earlier. But I still use less pre- and intra-operative testing than most (at least when I control the plethora of tests often ordered) and my morbidity and success rate seems unchanged.
We should welcome a text, which focuses on the technical aspects of minimally invasive surgery, but remains comprehensive and inclusive of disease management approaches which ultimately are the only way to improve overall outcome.
I am cautiously optimistic that by the time I need my first procedure for malig-nancy minimally invasive techniques will be at such a level that I can contemplate the same outcome as I might from the open approach but with less pain, morbidity, and no need for an incisional hernia repair! I shall not need a hysterectomy; I will be pleased to have a distal pancreatectomy. But if you need to convert, convert early . As for my thyroidectomy, a robot assisted thyroidectomy by the bilateral axillo-breast approach (BABA) is not for me . A small neck incision cannot possibly make me look worse than I do now, and I do not want to risk lymphedema.
In the meantime, given my secondary interest in sarcoma, it is hard to envision minimally invasive surgery dealing with a 15-kg retroperitoneal soft tissue sarcoma. So my timing is right; it will take a little longer to solve that problem with a minimal-ist approach. I congratulate the editors and their authors.
Prof. Murray F. Brennan, M.D.Memorial Sloan-Kettering Cancer Center,
1225 York Avenue, New York, NY 10065, USA
1. Jayaraman, S., Gonen, M., Brennan, M.F., D’Angelica, M.I., DeMatteo, R.P., Fong, Y., et al.: Laparoscopic distal pancreatectomy: evolution of a technique at a single institution. J. Am. Coll. Surg. 211(4), 503–509 (2010)
2. Lee, K.E., Koo do, H., Kim, S.J., Lee, J., Park, K.S., Oh, S.K., et al.: Outcomes of 109 patients with papillary thyroid carcinoma who underwent robotic total thyroidectomy with central node dissection via the bilateral axillo-breast approach. Surgery. 148(6), 1207–1213 (2010)
The view of a pioneer in Minimally Invasive Surgery
There can be little doubt that the introduction of laparoscopic surgery in the mid 1980s has had a far reaching effect on surgical practice. In many ways, this development has to be categorized as disruptive as defined by Christensen in his book the Innovator’s Dilemma, because it has radically changed the way in which we, as clinical surgeons, manage and treat our patients. From the early years of cholecystectomy and appendec-tomy, the scope of laparoscopic surgery has expanded to the safe execution of major operations for life threatening disorders across all surgical specialties, imparting sig-nificant benefits primarily to the immediate outcome of patients and to surgical health-care in general. The technology has continued to progress as has the surgical approaches exemplified by natural orifice and single incision laparoscopic surgery, in the quest for reduction of the traumatic insult to our patients. In some respects this progress has exceeded the expectations of the early pioneers with the advent of HDTV imaging systems and robotic surgery. To a very large extent, traditional open surgery now serves as a fall-back approach used whenever the minimally access approach proves difficult for whatever reason. This is as it should be, as surgical operations must never be considered as feats (the macho phenomenon) but simply as the appropriate means to cure or palliate patients for whom our profession exists to serve.
The concerns that the laparoscopic approach by virtue of the positive capnoperi-toneum somehow compromises the clinical outcome including cure rates of patients with cancer by enhancing the risks of wound recurrence and distant spread have been disproved by seminal studies including RCTs, such that we have now level I evidence on the equivalent cure rates between the open and the laparoscopic approach for cancer surgery, certainly for colon cancer. Paradoxically, the major expansion of the laparoscopic approach witnessed in the last 10–15 years has been in surgery for solid cancers. It is timely therefore that all these significant advances are brought together for the benefit of practicing surgeons. In this respect the two Editors, Ronald Matteoti and Stanley Ashley, are to be complimented for recruiting leading contributors for Minimally Invasive Surgical Oncology which, in my view, achieves its objective in providing a state-of-the art account. It provides a wealth of information on all the topics which should be of considerable interest to both estab-lished surgical oncologists and residents. Appropriately in my opinion, the first 10 chapters deal with general issues and technological advances relevant to oncologi-cal practice and are followed by specific chapters on the laparoscopic treatment
x Foreword II
of the various solid cancers within the specialties of general surgery, endocrine surgery, gynecology, thoracic surgery, and urology. I know of no other reference textbook which covers the entire subject matter in such detail, and compliment the two Editors and all their Contributors for a seminal volume which has been long overdue.
Prof Sir Alfred Cuschieri, FRSEInstitute for Medical Science and Technology,
University of Dundee, Wilson House,1 Wurzburg Loan, Dundee Medipark,
Dundee, DD2 1FD, UK
Minimally Invasive Surgical Oncology: State-of-the-Art Cancer Management offers a unique compendium of the current knowledge and applied techniques in treating cancer with a minimally invasive approach. It is a comprehensive text trying to cover all fields in oncology where minimally invasive surgery is currently used. The book is divided into two sections. Section one covers general topics ranging from historical aspects of the field to research in oncology, covering topics like residency training and includes contributions special to oncology like immunology and changes in elderly patients. Section two is subdivided into 25 chapters, organ-based, covering all aspects of minimally invasive surgery in the cancer patient in a unique way. At the end of each chapter the reader will find a section about future trends and a quick ref-erence guide to the specific topic and procedure. More so, the accompanying DVD offers tips and tricks by experts in the field explaining their surgical approach in a step-by-step fashion.
The ever growing field of minimally invasive surgery in combination with a better understanding of the consequent immunological and pathophysiologic changes has led to applications of minimally invasive approaches to maximally invasive disease processes. Over almost 2 decades, this field has rapidly evolved and there is almost no disease process and organ which has not been addressed. Despite this, oncologic diseases have always been addressed with great reservation and, for a long time, it was thought that cure could only be safely achieved with traditional open surgery.
When we first talked about the concept of the book we quickly realized that there is no existing book focused on the topic. All that was available were surgical atlases, case reports, and some randomized studies, particularly for covering colorectal malig-nancies. There was no clear guide of how to apply these techniques with maximal short- and long-term benefit to cancer patients. Our goal was to give the reader a bet-ter understanding of how the proven advantages of minimally invasive surgery could factor into an individualized surgical treatment plan, understanding that management of cancer is always multidisciplinary.
Minimally Invasive Surgical Oncology: State-of-the-Art Cancer Management brings together the expertise of not only experts but true leaders and pioneers in the field. It provides clear explanations of all surgical procedures as outlined in the table of contents but is, by far, more than just another surgical atlas. Current nonsurgical therapies, future trends, and alternative procedures are discussed with a quick refer-ence guide and a multimedia section. We hope that the unique structure of this book
will particularly be helpful to those engaged in treating oncological patients, contrib-ute to a wider acceptance of the application of minimally invasive techniques in malignancies and might open up new avenues for future research.
Philadelphia, PA, USA Ronald MatteottiBoston, MA, USA Stanley W. Ashley
“The smaller the incision, the bigger the surgeon’s concern should be to do the right procedure for the right patient at the right time.”
2010 Ronald Matteotti
“The cleaner and gentler, the act of operation, the less pain the patient suffers, the smoother and quicker the convalescence, the more exquisite his healed wound, the happier his memory of the whole incident.”
1920 Lord Moynihan
Ronald Matteotti, MD is a graduate of Gymnasium Vaduz, Principality of Liechtenstein and Medical College University of Basel, Switzerland. He completed a residency in general surgery and thereafter joined the faculty of Kreisspital Männedorf, Faculty of Surgery, University of Zurich, Switzerland. In Zurich, he was responsible for building up a minimally invasive surgical unit. In 2003 he joined the research staff of Prof. Gagner at his Minimally Invasive Surgical Unit at Mount Sinai Hospital, New York, NY and Weill-Cornell College of Medicine. After 2 years in research with Prof. Gagner he completed an advanced laparoscopy fellowship at Boston University in Boston, Massachusetts as the first Karl Storz “Surgical Innovation and Advanced Laparoscopy fellow.” Realizing the tremendous opportunities in the USA he completed a second residency at University Hospital of Cleveland, Case Western Reserve, Cleveland, OH. He moved on to Fox Chase Cancer Center in Philadelphia, where he served as a fellow in surgical oncology. Dr Matteotti holds specialty certificates in general, gastrointesti-nal, and trauma surgery. His primary interest is hepatobiliary disease and gastrointes-tinal cancer, especially minimally invasive approaches to gastric and colo-rectal malignancies. His research founded at Mount Sinai Hospital and further at Fox Chase Cancer Center includes pathophysiological changes during laparoscopy in a sepsis model and currently novel targets to treat hepato-cellular cancer. He has multiple pub-lications in the field of minimally invasive surgery and was the founding editor of the open access journal “Annals of Surgical Innovation and Research” where he currently is the editor in chief. He is a member of multiple professional societies especially SAGES – Society of Gastrointestinal end Endoscopic Surgeons.
Ronald S. Matteotti, MD, FMH Editor in ChiefSurgical Oncologist/Minimally Invasive Surgeon263 Osborn StreetPhiladelphia, PA 19128, USA
xvi Editor’s Biographies
Stanley W. Ashley, MD is a graduate of Oberlin College and Cornell University Medical College. He completed a residency in general surgery at Washington University in St. Louis and subsequently joined the faculty. He spent 7 years at UCLA before assuming his current position at Brigham and Women’s Hospital/ Harvard Medical School in 1997. He is currently the Frank Sawyer Professor and Vice Chairman of the Department of Surgery. He is also Program Director of the General Surgery Residency and Chief of General Surgery for Harvard Vanguard Medical Associates. Dr. Ashley is a gastrointestinal surgeon whose primary interests are dis-eases of the pancreas and inflammatory bowel disease. His research, which has been funded by both the VA the NIH, has examined the pathophysiology of the small bowel and pancreas. He has more than 250 publications. He serves on numerous editorial boards, including the Journal of Gastrointestinal Surgery, the Journal of the American College of Surgeons, Current Problems in Surgery, and ACS Surgery. He is currently a director of the American Board of Surgery and will serve as Vice Chair and then Chair from 2010 to 2012. He is a member of the Board of Trustees of the Society for Surgery of the Alimentary Tract.
Stanley W. Ashley, MD, FACSCoeditor-in-Chief Frank Sawyer Professor and Vice ChairmanDepartment of SurgeryBrigham and Women’s Hospital/Harvard Medical School Boston, MA 02115, USA
For Sandra who stood at my side all this time.
ToStanley W. AshleyWho always supported this project as coeditor without any reservations, adding his invaluable input and experience.
ToMichel Gagner and Jeffrey PonskyTwo pioneers, creative minds, thought leaders, and real friends.Without you two as mentors I would not be where I am right now and this book would never have been possible without your continued inspiration.
ToRonald MatteottiWithout whose vision and effort this project would not have been possible.
5-FU 5-FluorouracilABC Argon Beam CoagulationABMS American Board of Medical SpecialtiesABVD Adriamycin, Bleomycin, Vinblastine, DacarbazineAC Anesthesia ControlACC Adrenocortical CarcinomasACGME Accreditation Council for Graduate Medical EducationACS American College of SurgeonsACTH Adreno Cortico Tropes HormonADEPT Advanced Dundee Endoscopic Psychomotor TesterAESOP Animated Endoscopic System for Optimal PositioningAGES Age, Tumor Grade, Extent, SizeAHPBA The American Hepato-Pancreato-Biliary AssociationAJCC TNM American Joint Committee on Cancer Tumor Node MetastasisAJCC/UICC American Joint Committee on Cancer/International Union Against
CancerAMES Age, Metastasis, Extent, SizeANED Alive with No Evidence of DiseaseAP Anterior-PosteriorAPDS Association of Program Directors in SurgeryAPR Abdominoperineal ResectionAPUD Amine Precursor Uptake and DecarboxylationARR Aldosterone to Renin RatioASCRS American Society of Colon and Rectal SurgeonsASGE American Society of Gastrointestinal EndoscopyASIS Anterior Superior Iliac SpineASMBS American Society for Metabolic and Bariatric SurgeryASTRO American Society of Therapeutic Radiology and OncologyATA Anterior TransabdominalAWD Alive With DiseaseBABA Bilateral Axillary-Breast ApproachBCR-ABL Breakpoint Cluster Region-Abelson Murine LeukemiabDFS biochemical Disease-Free SurvivalBEACOPP Bleomycin, Etoposide, Adriamycin, Cyclophosphamide, Vincristin
= Oncovine, Procarbazine, PrednisoneBED Biologic Effective DoseBMI Body Mass Index
Size of the Primary TumorMALT Mucosa-Associated Lymphoid TumorMC Mammary Cancer CellsMCT Microwave Coagulation TherapyMEMS Micro Electro Mechanical SystemsMEN Multiple Endocrine NeoplasmMEN 1 Multiple Endocrine Neoplasia 1MEN 2 Multiple Endocrine Neoplasia type 2MHC-II Major HistocompatibilityComplex-IIMI Myocardial InfarctionMIBG Metha-Ido-Benzo-GuanidineMIE Minimally Invasive EsophagectomyMIRS Minimally Invasive Robotic SurgeryMIS Minimally Invasive SurgeryMISTELS McGill Inanimate System for Training and Evaluation
of Laparoscopic SkillsMIST-VR Minimally Invasive Surgical Trainer-virtual RealityMIT Minimally Invasive Open TechniqueMIT Minimally Invasive Open ThyroidectomyMIVAT Minimally Invasive Video Assisted ThyroidectomyMMPs Matrix MetalloproteinsMN MinnesotaMR Magner ResonanceMRC CLASIC Multicenter Randomized Comtrolled Trial of Conventional versus
Laparoscopic-AssistedMRI Magnetic Resonance ImagingMSI-H High Microsatellite InstabilityMTC Medullary Thyroid CancermTOR Surgery in Colorectal CancerMVP Maryland Virtual PatientNCCN National Comprehensive Cancer NetworkNCI National Cancer InstituteNE NeuroendocrineNED No Evidence of DiseaseNET Neuroendocrine Tumor
NG Naso-GastricNHANES National Health and Nutrition Examination SurveyNHL Non-Hodgkin’s LymphomaNIS Sodium Iodide SymporterNK Natural KillerNK-LGL NK-Large Granular LymphocyteNOSCAR Natural Orifice Surgery Consortium for Assessment and ResearchNOTES Natural Orifice Transluminal Endoscopic SurgeryNOTUS Natural Orifice Trans Umbilical SurgeryNPO Nil Per OsNS Not SignificantNSADS Non-Steroidal Antiinflammatory DrugsNSQUIP National Surgical Quality Improvement ProgramNSS Nephron-Sparing SurgeryOC Open ColectomyODG Open Equivalent GastrectomyOGT Oral Gastric TubeOPUS One Port Umbilical SurgeryOR Operating RoomOR Open ReconstructionOR time Mean Operating Room TimeOSATS Objective Structured Assessment of Technical SkillOST Overnight Low-Dose Dexamethasone Suppression TestPACE Preoperative Assessment of Cancer in the ElderlyPALND Para Aortic Lymph Node DissectionPBMC Peripheral Blood Mononuclear CellsPDS Polydioxanone SuturePDT Photodynamic TherapyPE Pulmonary EmbolismPECAM1 Platelet Endothelial Cell Adhesion Molecule 1PEG Percutaneous Endoscopic GastrostomyPET Positron Emission TomographyPF Pancreatic FistulaPFT Pulmonary Function TestPGE2 Prostaglandin E2PHP Primary HyperparathyroidismPIP Picture-In-PicturePL Pure LaparoscopicPlGF Placental Growth FactorPLN Pelvic Lymph NodePLND Pelvic Lymph Node DissectionPMCA Peritoneal Mucinous CarcinomatosisPME Partial Mesorectal ResectionPMN Polymorphonuclear LeukocytePMP Pseudomyxoma PeritoneiPN Partial NephrectomyPOD Postoperative DayPOG Pediatric Oncology GroupPRAD1 Parathyroid Adenomatosis 1
PSA Prostate-specific AntigenPTC Papillary Thyroid CancerPTH Parathyroid HormonePV Portal VeinQOL Quality of LifeR/O Ruled/OutRA Renal ArteryRAI Radioactive IodineRALPN Robot-Assisted Laparoscopic Partial NephrectomyRAS Rat SarcomaRB RetinoblastomaRCC Renal Cell CarcinomasRCT Randomized Controlled TrialREA Retroperitoneal AdrenalectomyRFA Radiofrequency AblationRLL Right Lower LobectomyRLN Recurrent Laryngeal NerveRML Right Middle LobectomyRMS RhabdomyosarcomaRN Radical NephrectomyRPP Radical Perineal ProstatectomyRRP Radical Retropubic ProstatectomyRTOG Radiation Therapy Oncology GroupRT-PCR Reverse Transcription Polymerase Chain ReactionRUL Right Upper LobectomyRUQ Right Upper QuadrantSAE Splenic Artery EmbolizationSAGES The Society of American Gastrointestinal and Endoscopic SurgeonsSARA Single Access Retroperitoneoscopic AdrenalectomySCD Sequential Compression DeviceSCM Sternocleidomastoid MuscleSCT Sacro Coccygeal TeratomaSCUE Single-Channel EndoscopeSD Standard DefinitionSEER Surveillance Epidemiology and End ResultsSEMS Self-Expandable Metal StentsSILS Single-Incision Laparoscopic SurgerySILS Single Port Laparoscopic SurgerySIOP International Society for Pediatric OncologySMA Superior Mesenteric ArterySMV Superior Mesenteric VeinSPA Single Port AccessSRMs Small Renal MassesSSAT The Society for Surgery of the Alimentary TractTACE Transarterial ChemoembolizationTAE Transarterial EmbolizationTAH Total Abdominal HysterectomyTCC Transitional Cell CarcinomaTAä Triangular Anastomosis
TEM Trans-Anal Endoscopic MicrosurgeryTEMS Trans-Anal Endoscopic MicrosurgeryTG TransgastricTHOR Conventional ThoracotomyTID Ter in Die (Thrice Daily Dosage)TLH Total Laparoscopic HysterectomyTLRP Transperitoneal Laparoscopic Radical ProstatectomyTME Total Mesorectal ExcisionTNsyF Tumor Necrosis FactorTNF-a Tumor Necrosis Factor AlphaTNM Tumor, Node, MetastasesTRH Thyrotropin-Releasing HormoneTRUS Transrectal UltrasoundTSH Thyroid-Stimulating HormoneTUES Trans Umbilical Endoscopic SurgeryTULA Trans Umbilical Laparoscopic AssistedTUR-B Transurethral Resection of the BladderTUR-P Transurethral Resection of the ProstateTV TelevisionUFC Urinary-Free Cortisol EvaluationUGI Upper Gastro-Intestinal ImagingUNS Unilateral Nerve SparingUS UltrasoundUTI Urinary Tract InfectionUVF Uretero-Vaginal FistulaVATS Video-Assisted Thoracic SurgeryVC Vena CavaVCAM Vascular Cell Adhesion MoleculeVEGF Vascular Endothelial Growth FactorVHS Video Home SystemVR Virtual RealityVVF Vesico Vaginal FistulaWIT Warm Ischemia TimeYAG Yttrium Aluminum Garnet
List of Videos
Chapter 11 Cancer of the Esophagus and the Gastroesophageal Junction: Two-Cavity ApproachChristopher R. Morse, Omar Awais, and James D. Luketich
The two cavity approach to esophageal cancer
Chapter 12 Cancer of the Esophagus and the Gastroesophageal Junction: Transhiatal ApproachLee Swanstrom and Michael Ujiki
Clip 1 Division of the gastro-colic ligament (case 1)Clip 2 Division of the gastro-colic ligament(case 2)Clip 3 Dissection of the right gastro-omental vessels and of the
inferior side of the proximal duodenum (case 1)Clip 4 Dissection of the right gastro-omental vessels (case 2)Clip 5 Vascular lesions on the right gastro-omental vesselsClip 6 Dissection of the gastro-hepatic ligament up to the hepatic
common artery (case 2)Clip 7 Dissection of the gastro-hepatic ligament up to the hepatic
common artery (case 1)Clip 8 Division of the right gastric arteryClip 9 Posterior dissection and division of the duodenum (case 2)Clip 10 Posterior dissection and division of the duodenum (case1)Clip 11 Dissection of the common hepatic arteryClip 12 Lymphadenectomy of nodal stations 7, 8 and 9Clip 13 Division of the stomach Clip 14 Exposure of the stomach by trans-abdominal suspensionClip 15 Trans-mesocolic route and approximation of the stomach to
the mesocolonClip 16 Gastro-jejunal anastomosis, closure of the mesocolic window
and extraction of the specimen (case 1)Clip 17 Gastrojejunal anastomosis (case 2)
xxxii List of Videos
Chapter 14 Laparoscopic Total Gastrectomy – LATGSeigo Kitano, Norio Shiraishi, Koji Kawaguchi, and Kazuhiro Yasuda
Laparoscopic total gastrectomy with Roux-En-Y reconstruction
Chapter 15 Endoluminal Procedures for Early Gastric CancerBrian J. Dunkin and Rohan Joseph
Endoluminal procedures for early gastric cancer
Chapter 16 Laparoscopic Management of Small Bowel TumorsMiguel Burch, Brian Carmine, Daniel Mishkin, and Ronald Matteotti
Laparoscopic management of small bowel tumors
Chapter 17 Right Hemicolectomy and AppendixAntonio M. Lacy
Right hemicolectomy and appendectomy for cancer
Chapter 18 Left Hemicolectomy and Sigmoid ColonJoel Leroy, Ronan Cahill, and Jacques Marescaux
Laparoscopic Sigmoidectomy for cancer
Chapter 19 Laparoscopic Rectal ProceduresRolv-Ole Lindsetmo and Conor P. Delaney