LAPAROSCOPIC COLON RESECTION -

Anterior Approach

Sandeep Malhotra, MD

Scott Steinberg, MD

George Ferzli, MD, FACSProfessor of Surgery, SUNY Downstate Health Science Center, Brooklyn, NY

Anterior Approach

• Patient supine

• Position hand over sigmoid and rotate in semi-circle to place trocars (3)

Trocar Placement : Anterior Position

Anterior position

1

2

Trocar in inguinal crease cuts sigmoid

Repair - Anterior Position

If proximal colon can be brought through inguinal crease trocar incision, tension free repair will be successful

Anterior Approach

Anterior Approach

Laparoscopic Sigmoid ColectomyTotal (n) = 62 pts Lateral (24) Anterior (38)

Age 48 (32 - 70) 46 (27 - 86)

Sex, M:F 23:1 35:3

Indications:

• Diverticulitis 16 (2 abscess) 20 (4 abscess)

• Polyp 3 6

• Carcinoma 5 12

Complications 1 hematoma flank,

1 re-op for SBO,

1 leak (cut.drainage)

1 leak (re-op hartman)

Hospital Stay 2.2 (2 - 10) 2.4 (2 - 9)

OR Time 142 (98 – 216) 147 (110 – 279)Ferzli G et al. (2000 – 2001) Unpublished Data

Laparoscopic Versus Open Colectomy for Cancer

Colorectal ResectionLaparoscopic vs. open resection for carcinoma

0

10

20

30

40

RHC Trans AR Sig LAR APR Total

Ave

. # ly

mp

h no

des

0

5

10

15

20

25

RHC Trans AR Sig LAR APR

Ave

. spe

cim

en le

ngth

, cm

0

4

8

12

16

20

RHC Trans AR Sig LAR APR

Ave

. dis

tal m

arg

in, c

m

LCR OCR

0

7

14

21

28

35

RHC Trans AR Sig LAR APR

Ave

. pro

xim

al m

arg

in, c

m

LCR OCR

RHC = Right hemicolectomy; Trans = Transverse; AR = Anterior resection; Sig = Sigmoid; LAR = Low anterior resection; APR = Abdominoperineal resection

Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46

Colorectal ResectionLaparoscopic vs. open resection for carcinoma

Laparoscopic

(n=192)

Open

(n=224)

Hospitalization, days 5.6 9

Blood loss, mL 150 450

Wound complications 0.5% 6%

Recurrence rates 12.2% 22%

Cumulative death and recurrence rates 5 years into the study (Stages I, II, and III)

13% 19.1%

Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46

Colorectal ResectionLaparoscopic vs. open resection for carcinoma

Follow-up Lap. Open

No. of cases (n) 40 43

Overall metastases 8 (20%) 10 (23%)

Single site metastases 3 5

Liver 2 4

Regional 1 1

Multiple site metastases 5 5

Liver+ Peritoneum 4 4

Liver+Peritoneum+

Trocar-site or scar

1 1

Five-year overall survival

0

20

40

60

80

100

0 12 24 36 48 60

Follow-up (months)

Sur

viva

l (%

)

Five-year disease-free survival

0

20

40

60

80

100

0 12 24 36 48 60

Follow-up (months)

Sur

viva

l (%

)

Lap OpenSantoro E et al, Hepato-Gastroenterology 1999; 46:900-904

Colorectal ResectionLaparoscopic vs. open resection for carcinoma

Lap (n=18) Open (n=18) Converted (n=7)

Operating room time (min) 210 138 242

Blood loss (mL) 284 407 683

ICU stay (days) 3 4 6

Clear liquids (days) 2.7 4.4 5

Regular diet (days) 4.1 5.8 7

Length of stay (days) 5.2 7.3 8

Complications (n, %) 1, 5% 5, 28% 8, 100%

Length of specimen (cm) 26 26 32

Number of lymph nodes 11 10 12

Late death from cancer (mean follow-up 4.9 years)

4 6 1

Recurrence 0 1 1

Curet MJ et al, Surg Endosc (2000) 14: 1062-1066

Long-Term Survival After Laparoscopic Colon Resection For Cancer

• Aim: To evaluate long-term survival after curative, laparoscopic resection for colorectal cancer.

• Design: Retrospective review of 102 consecutive patients with laparoscopic colon resection between 1991 and 1996 with 5-year follow-up. Comparison made to open colectomy at the same institution and National Cancer Database during similar time period.

Lujan HJ et.al. Dis. of Colon and Rectum;45:491-405,April 2002

Long-Term Survival After Laparoscopic Colon Resection For Cancer

02040

6080

100

0 1 2 3 4 5

Time in years

% s

urv

iva

l

Lap

Open0

20406080

100

0 1 2 3 4 5

Time in years

% s

urvi

val

Stage I Stage II Stage III Stage IV

Long-Term Survival After Laparoscopic Colon Resection For Cancer

02040

6080

100

0 1 2 3 4 5

Time in years

% s

urv

iva

l

Lap

Open – Nat.Ca. Database

020406080

100

0 1 2 3 4 5

Time in years

% s

urvi

val

Stage I Stage II Stage III Stage IV

Long-Term Survival After Laparoscopic Colon Resection For Cancer - Conclusions

• Laparoscopic colectomy for cancer is safe and feasible

• 5-year survival after laparoscopic colon resection for cancer is similar to survival after conventional surgery

• Prospective randomized trials currently under way will likely confirm these results

Lujan HJ et.al. Dis. of Colon and Rectum;45:491-405,April 2002