Η Λαπαροσκοπική Χειρουργική στον Καρκίνο του Παχέος...
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Η ΛΑΠΑΡΟΣΚΟΠΙΚΗ ΧΕΙΡΟΥΡΓΙΚΗ ΣΤΟΝ
ΚΑΡΚΙΝΟ ΤΟΥ ΠΑΧΕΟΣ ΕΝΤΕΡΟΥ ΚΑΙ ΤΟΥ
ΟΡΘΟΥ
ΔΗΜΗΤΡΗΣ Π. ΚΟΡΚΟΛΗΣΧΕΙΡΟΥΡΓΟΣ
ΔΙΔΑΚΤΩΡ ΙΑΤΡΙΚΗΣ ΣΧΟΛΗΣ ΠΑΝΕΠΙΣΤΗΜΙΟΥ ΑΘΗΝΩΝ
ΕΠΙΜ. Α’
ΑΟΝΑ «Ο ΑΓΙΟΣ ΣΑΒΒΑΣ»
ΕΠΙΔΗΜΙΟΛΟΓΙΑ
One of the most common cancers in the world
US: 4th most common cancer (after lung, prostate, and breast cancers)
2nd most common cause of cancer death(after lung cancer)
2007: 130,000 new cases of CRC 56,500 deaths caused by CRC
ΑΝΑΤΟΜΙΑ
ΑΝΑΤΟΜΙΑ
ΑΝΑΤΟΜΙΑ
Typical sites of incidence and sympoms of colon cancerΕΝΤΟΠΙΣΗ - ΣΥΜΠΤΩΜΑΤΟΛΟΓΙΑ
A-B right hemicolectomy
A-C extd right hemicolectomy
B-C transverse colectomy
C-E left hemicolectomy
D-E sigmoid colectomy
D-F anterior rection
D-G (ultra) low anterior resection 32025 Anastomosis <10cm from anal verge
32026 Anastomosis <6cm from anal verge
D-H abdomino-perineal resection
A-D subtotal colectomy
A-E total colectomy
A-H total procto-colectomy
A
B C
D
E
F
GH
© CCrISP Australasia 3rd Edition
Colorectal Major Resections
Rectal Ca Radical excision - Left colon mobilization
• Splenic flexure mobilization
• Sigmoid colon resected– Quality of circulation is poor– Functional outcomes as neo-rectum poor
• High ligation of IMA– Allows mobilization of descending colon
• Ligation of main trunk of left colic
Radical excision-Total Mesorectal Excision(TME)
• Introduced by RJ Heald in 1979• Use of sharp dissection under vision to mobilize the rectum
rather than the conventional blunt finger dissection• First series of 112 pts: 5yr LR 2.9% and survival 87.5%• Local recurrence:
– Conventional surgery: 11.7 - 37.4%– TME surgery: 1.6 - 17.8%
• Higher leaks rates reported possibly due to:– Devascularisation of distal rectal stump– Lower anastomosis– Other factors: stomas, drains
TME - Technique
• Peritoneal incision around rectum• Rectosigmoid reflected ant and posterior avascular plane
developed using sharp scissor or diathermy dissection under vision
• Blobbed lipoma should be demonstrated• Posterior dissection first, then lateral and finally anterior
dissection• Do not ‘finger hook’ or clamp the lateral ‘ligaments’• Partial TME to a distance 5cm distal to tumour• Anterior dissection incorporates Denonvilliars fascia?
TME - Technique
TME - Fascial envelope
TME Specimen
TME - Nerve injury
Preaortic sympathetics during high ligationSympathetics at the pelvic brim during rectal mobilizationParasymp(nervi erigentes) and sympathetics during
posterolateral dissection No clear lateral ligaments Do not hook or clamp these tissues, avoid excessive traction Higher rates exp by Japanese with extended lateral LN dissection
Anterior lateral dissection off the prostatic capsule The most likely area of damage, reflected by higher rates of sexual
dysfunction in APR(14-51%) vs AR(9-29%) The role of denonvilliars fascia
TME - Distal resection margin
• Not clear in the literature • 5cm preop will expand to 7-8cm on
rectal mobilization• This will shrink to 2-3cm with specimen
removal and formalin fixation• Rare for tumour to spread beyond 1.5cm• Rare reports of poorly diff tumours
having spread 4.5cm distally• Recommend: 5cm ideally however 2cm
is adequate
Reconstruction of Neorectum
• Hand sewn sutured anastomosis– 1982: Parks and Percy performed the coloanal sutured anastomosis– ‘Pulled through’ colo-anal anastomosis (Turnbull & Cuthbertson)
• Stapled anastomosis– Circular stapled technique– Double stapler technique
• For low and colo-anal anastomosis
Reconstruction of Neorectum
Straight end to end Low AR or Coloanal end-to-end anastomosis cause tenesmus, urgency and
incontinence (Anterior resection syndrome)
Colonic J Pouch Increases volume of neorectum 5 vs 10cm pouches have smaller reservoirs but better evacuation
(Hida et al., Ds Colon Rectum 1996) Size is critical to functional outcome, recommend 5-8 cm Sigmoid colon should not be used Better short term functional results and possible lower anastomotic leaks
compared to end-to-end anastomosis
Transverse Coloplasty New technique introduced in 1999 (Z’graggen et al., Dig Surgery 1999) Better in narrow pelvis and limited length of colon Long incision closed transversely Randomized trial underway comparing to J-pouch
Reconstruction of Neorectum
Straight End to End Anastomosis
Reconstruction of Neorectum
Colonic J-pouch
Transverse Coloplasty
Abdominoperineal Resection
• Described by Sir Ernest Miles 1908• 1-2 surgeons• TME rectal dissection • Anus sutured closed• Wide perineal dissection, starting from posterior to lateral then anterior• Anterior dissection can proceed cranio-caudal or vice versa• SB exclusion - omentum or absorbable mesh• Drain the pelvic space• Reduced rates of APR
– Coloanal anastomosis– Acceptance of smaller margins– Downsizing by chemoradiotherapy
Laparoscopic Colorectal Surgery
History
• 1982 Semm performed first Laparoscopic Appendicectomy
• 1987 Mouret performed first Laparoscopic Cholecystectomy
• 1992 First UK Laparoscopic Training centres established
Laparoscopic Colorectal Cancer Resections
1990 2003
Rewards of Minimally Invasive Techniques
Operative TimeCost
Benefits ofNew
Techniques
Risk/EffectsOf Anesthesia,Trauma, Etc.
Background
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 for oncological soundness› Possible port site metastases
Preoperative Considerations• Site (Right and sigmoid easier)• Tumor size/invasion• Obesity• Previous surgery• Almost always get a pre-op CT (cancer)• Must talk with patient about need for conversion
to open• Must be able to find tumor/polyp (tattoo!, 0.5cc
India ink in 3-4 sites)
Tattoo
Preoperative ConsiderationsContinued
• Can also locate with BE• Having to do intraoperative colonoscopy is a
flail– CO2 colonoscopy may be better
• Bowel Preparation – Utility is debatable, but with laparoscopy it makes
bowel easier to handle
Conversion to Open• 10-25%
– Obesity– Prior surgery– Acute inflammation
• Fistula – 50% conversion
– Tumor bulk
• Not a failure• Early conversion preserves good outcomes
(Wolff, 2007)
What difference does it make?
Laparoscopic Colectomy
•It helps you get a job•Patients like it (thanks to the internet)•Referring doctors like it•But what difference does it really make
Outcomes
• Ileus – average 1-2 days shorter with laparoscopy
• Less need for narcotics• Quicker return of pulmonary function• Length of stay ~1 day less• May be influenced by biased expectations
– Who cares?
(Wolff, 2007)
Outcomes – Page 2
• Return to work and quality of life– No statistical change– Anecdotally improved
• Cost– Equipment costs and OR time are greater– May be balanced or outpaced by shorter hospital
stay
• Time – Average 30-60 minutes longer
(Wolff, 2007)
Port-Site Metastasis
• Initial concern greatly slowed development of laparoscopic colectomy
• Not born out in major trials
Port site recurrence
• 1-21% incidence• 3 of 14 patients
• ASCRS registry 1.1%• Incidence in open wounds = 1%
• Not a problem
Specific Trials
• Antonio Lacy• COST• COLOR• MRC CLASSIC
Antonio Lacy, et al 2002
• 219 patients
(Lacy et al, 2002)
Antonio Lacy, et al
Overall Survivalp=0.16
Cancer Related Survivalp=0.02
(Lacy et al, 2002)
Antonio Lacy, et al 2008
(Lacy et al, 2008)
COST TrialClinical Outcomes of Surgical Therapy Study Group
• 872 patients with colonic adenocarcinoma• Recurrence
– 16% lap– 18% open
• Survival– 86% lap– 85% open
• Post-operative stay– 5 days lap– 6 days open
(COST Study, 2004)
COST TrialClinical Outcomes of Surgical Therapy Study Group
• 5 year data published October 2007• Disease-free 5 year survival
– 68.4% Open– 69.2% Laparoscopic
• Overall survival– 74.6% Open– 76.4% Laparoscopic
• Recurrence– 21.8% Open– 19.4% Laparoscopic
(COST Study, 2007)
COLOR TrialCOlon cancer Laparoscopic or Open Resection
• 1248 patients• 17% conversion to open• BMI>30 excluded (because started in 1997)
• Pathologic criteria no different• Time to GI recovery, 1st BM, hospital stay all
one day less• Complications were equivalent
(COLOR Trial, 2005)
MRC CLASSICCMedical Research Council trial of Conventional versus Laparoscopic-ASsisted Surgery In Colorectal Cancer
• 794 patients• Pathologic specimens, complications were
similar• Time to 1st BM 1 day shorter• Time to diet and discharge similar between
groups
(Guillou et al, 2005)
Cumulative Incidence of Recurrence at Any Stage
Overall Survival at Any Stage
Long – Term Results in Colon Cancer
Lai JH, et al. Br Med Bull 2012
Hand Assisted Laparoscopy vs.“Pure” Laparoscopy
• May reduce learning curve• May be used “up front” or as a “pseudo-conversion”• Need to make an incision large enough for the
specimen anyway• Outcomes similar to laparoscopy, with operative
times usually shorter
Applied Medical Gelport
Laparoscopic Left HemicolectomyHand Approaches
Laparoscopic Left HemicolectomyHand Approaches
Hand-assist vs. Laparoscopy
(Targarona et al, 2002)
Hand-assist vs. Laparoscopy
(Targarona et al, 2002)
Hand-assist vs. LaparoscopyMarcello et al
• 95 patients - left or total colectomy• Randomized to HA vs LAP• Left colectomy
– 175 minutes HA, 208 LAP (p=0.021)– Flatus 2.5 vs 3 days (p=0.64)– Length of stay 5 vs 4 days (p=0.55)
• Total colectomy– 127 vs 184 minutes (p=0.015)
(Marcello et al, 2008)
In a comparison of “pure” laparoscopy and HALS, what does no significant difference mean?
It means that if you can do it more easily with one hand in, why not do it?
Techniques in Laparoscopic Colon and Rectal Surgery
Room Setup1) Radiological unit (optional)
2) Laparascopic unit
3) Anaesthetic unit
4) Laparascopic unit – extra monitors
5) Instrument table
6) Electrocautery
7) Operating table
Patient positioning
Access and Port Placement
Access and Port Placement
Trocars
Graspers
Harmonic Scalpel
Endoscopic Circular Stapler ECS29
Linear cutter stapler
Wound protector
Laparoscopic HemicolectomyTechnique
• Access• Takedown of previous adhesions• Mobilization and vascular division• Intestinal division• Anastomosis• Closure of mesenteric defect
– Usually skipped
• Closure
Right Hemicolectomy
Laparoscopic Colectomy
Port Placement: Right Hemicolectomy
Laparoscopic Right HemicolectomyApproaches
• Medial-Lateral• Inferior• Lateral-Medial• Top-Down
Largely
Independent of trocar
placement
Don’t burn the duodenum!Don’t laugh. It’s happened more than once.
(Netter, 1997)
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Left HemicolectomySigmoidectomy
Low Anterior Resection
Laparoscopic Colectomy
Port Placement: Left Hemicolectomy
Mobilization of the Sigmoid
Identification of the Ureter
Division of Mesentery
Rectal Resection
RetrorectalWindow
Colorectal Anastomosis
Laparoscopic Resection for Rectal Cancer
Should we do it?
TME - Gold Standard
• 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
Potential Advantages of Lap TME
• Less blood loss• Faster recovery• Earlier return of gut function• Lower morbidity• Magnified view allows precise dissection
(pelvic autonomics)
Potential Advantages of Lap TME
• Reduced pain• Improved cosmesis• Decreased adhesions• Decreased wound infection rate• Reduced immune effect of surgery
Potential Disadvantages
• Steep learning curve• Longer operating times (+30% to 50%)• Cost
– Instruments / equipment
• Port-site recurrence?• Oncological soundness compared with open
TME?
Potential Disadvantages
• 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
Techniques
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
New Technologies
• Optics / image Processing• Energy devices (e.g. harmonic scalpel, bipolar
energy)• New staplers• Wound protectors / retractors• Hand assist devices• Robotics?
New laparoscopes
•Smaller, better optical properties•Magnification 15-20X•Flexible
HD imagingHigh DefinitionStandard Definition
Operation Setup
• 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
Patient Positioning
Tilting
Theatre Setup
Port placement
Port placement HALS
IncisionIncision
Hand-Assisted Laparoscopic TME
May expedite the mid and upper abdominal steps
Technique: General principles
• Pre-operative assessment– Can / should it be done laparoscopically?
• Medial to Lateral dissection• High vascular division• Full mobilization of splenic flexure• Rectal dissection / division / anastomosis
Left Colon: Preparation
Right side IMA
Division of IMA & IMV
Left Colon: Lateral dissection
Omental Dissection:Right to left
Pelvic dissection
Rectal division
Rectal division:Hybrid / HALS
Anastomosis
Should We Go There?
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)
Laparoscopy: Rectal Cancer
Open Laparoscopic
Patients 89 82
Mean age (years) 45 44
Dukes’ StageABCD
68
687
510634
Prospective, Randomized, Controlled – Short-term outcome of TME with anal sphincter preservation (ASP)
Zhou, Surg Endosc 2004
Laparoscopy: Rectal CancerResults of Surgery
Open(n=89)
Laparoscopic(n=82)
Distance of Tumor from Dentate (cm)1.5-4cm4.1-7cm
5633
4834
Distal Margin 1.5-3.5 1.5-4.0
Sphincter preservation 100% 100%
Anastomotic heightLow anterior (>2cm from dentate)Ultralow anterior (<2cm from dentate)Coloanal (at or below dentate)
352727
302725
Diverting ileostomy 0 0
Zhou, Surg Endosc 2004
Laparoscopy: Rectal CancerOpen Laparoscopic P
value
Operative time (min) 106 120 NS
Blood loss (ml) 92 20 0.02
Parenteral analgesics (days) 4.1 3.9 NS
Solid intake (days) 4.5 4.3 NS
Hospitalization (days) 13.3 8.1 0.001
MorbidityAnastomotic leak
12.4%3
6.1%1
0.016
Mortality 0 0 NS
Follow-up 1-16 months
Port site mets NA 2
Pelvic recurrence 3 0
Zhou, Surg Endosc 2004
MRC CLASICC:Short term end-points of conventional vs laparoscopic-assisted
surgery in patients with rectal cancer
• 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
MRC CLASSIC:Results
• 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
MRC CLASSIC:Results
• Complications – rectal cancer– Intention to treat
• Open 37% Lap 40%
– Actual treatment• Open 37% Lap 32% Conversion 59% (p=0.002)
MRC CLASSIC:Results
OpenLap Conv
• Anaesthetic time* 135 180 180 mins• 1st BM 6 5
6 days• Normal diet 7 6
7 days• LOS 13 10
13 days
*Rectal and colonic resection
MRC CLASSIC:Results
• Cost – intention to treat (mean)
Open Lap
• Theatre £ 1448 £ 1816• Hospital £ 3713 £ 3359• Others £ 2659
£ 3085
• Total £ 7820 £ 8260Br J Cancer 2006 95:6-12
MRC CLASSIC:Results
• 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)
MRC CLASSIC:Conclusions
• CLASSIC group suggest that laparoscopic anterior resection is not justified as a routine approach due to concerns over:– Increased positive CRM rate– High morbidity with conversion
• Learning curve underestimated at the 20 cases used in the trial
Cochrane Review:Lap vs open TME for rectal cancer
• Breukink et al (2006)• 48 studies, 4244 patients• Poor study methodologies, only 3 RCT’s• No strong conclusions possible
Cochrane Review:Results
• 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)
Cochrane Review:Results
• Perioperative mortality– No significant difference
• Morbidity– No apparent difference– Trend towards lower complications in lap groups
• Anastomotic leak– No difference
Cochrane Review:Results
• 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
Cochrane Review:Results
• Lymph node harvest– No difference
• Postoperative recovery– Improved with lap TME
• Quality of life– Insufficient data
Cochrane Review:Results
• Cost– Probably increased for lap TME– Poor data
• Immune response to surgery– Appears reduced with lap TME
Cochrane Review:Conclusions
• No firm conclusions• Laparoscopic TME appears to have short term
benefits• Long term oncological safety requires further
randomized trials
Specific Issues
• Port-site hernia– 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
Specific Issues
• 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
Laparoscopy: Total Mesorectal Excision (TME) case control study
Breukink, Int J Colorectal Dis 2005
VARIABLE/GROUP LAPAROSCOPIC OPEN P value
OPERATIVE TIME(min) 200 180 0.06
BLOOD LOSS(ml) 250 1000 <0.001
>1000 ml FLUID INTAKE 3 6 0.002
SOLID DIET (days) 4 7 0.046
HOSPITALIZATION (days)
12 19 0.007
MORBIDITY 37% 51% N/A
ANASTOMOTIC LEAK (n)
2 2 N/A
MORTALITY(n) 0 1 N/A
Laparoscopy: Total Mesorectal Excision (TME) case control study
VARIABLE/GROUP LAPAROSCOPIC OPEN
CIRCUMFERENTIAL MARGIN(mm)
3 (2-31) 5 (2-31)
DISTAL MARGIN mm 35 (10-100) 10 (1-30)
NUMBER OF NODES 8 (1-25) 8 (2-20)
FOLLOW UP (months) 14 (2-31) 19 (2-31)
LOCAL RECURRENCE 0 0
DISTANT METASTASIS 5 5
Breukink, Int J Colorectal Dis 2005
N Conversion OR
Time(mins)
Anastomotic Technique
Goh, 97 OLARLLAR
2020
-0%
7390
Partial TME with double staple
Leung, 97 OLARLLAR
5050
-16%
150196
Partial TME with double staple
Schwander, 99 OLA/prLLA/pr
3232
-NS
209281
LAR 19 Lap 19 Open, APR 13 Lap 13 Open
Hartley, 01 OLA/prLLA/pr
2242
-50%
125180
LAR, APR, Hartmann
Anthuber, 03 OLA/prLLA/pr
334101
-11%
219218
TME with colonic J if <6cm
Breukink, 05 LARAPR
1031
NS 195225
Double stapled anastomosis
Laparoscopy: Rectal Cancer
Case controlled series for LAR
Length of Stay LRM DRM Morbidity Morbidity Leak
Goh, 97 OLARLLAR
5.55
clearclear
44.5
5%20%
NS 00
Leung, 97 OLARLLAR
86
clearclear
NS 30%26%
6%2%
2%0%
Schwander, 99 OLA/prLLA/pr
2115
clear clear 31%31%
0%3%
03%
Hartley, 01* OTMELTME
1513.5
0.80.65
2.54
18%26%
0%0%
14
Anthuber, 03 OLA/prLLA/pr
1914
DN DN 54% 31%
1%0%
7%9%
Breukink, 05 LARAPR
1121
NS 3.5 37% 0 5%
Laparoscopy: Rectal Cancer
N Conversion OR Time(mins)
Anastomotic Technique
Seow-Chen, 97 OAPRLAPR
1116
-NS
100110
TME
Ramos, 97 OAPRLAPR
1818
-10%
208229
TME
Fleshman, 99 OAPRLAPR
42152
-21%
209234
Lap APR with TME
Leung, 00 OAPRLAPR
3425
-NS
166216
TME
Baker, 02 OAPRLAPR
6128
-25%
NSNS
?TME
Laparoscopy: Rectal Cancer
Case controlled series for APR
Length of Stay LRM DRM Morbidity Mortality
Seow-Chen, 97 OAPRLAPR
86.5
clearclear
32
55%25%
0%0%
Ramos, 97 OAPRLAPR
12.97.4
NS NS 66%44%
5.5%0%
Fleshman, 99 OAPRLAPR
127
+ in 5+ in 19
NS 27%33%
0%0%
Leung, 00 OAPRLAPR
1625
NS 12
48%61%
0%0%
Baker, 02 OAPRLAPR
1813
+ in 1 3.24.5
-/3%-/4%
3%4%
Laparoscopy: Rectal CancerCase controlled series for APR
Laparoscopic vs. Open Surgery for Extraperitoneal Rectal Cancer
• 191 consecutive patients• 98 patients underwent lap resection • 93 patients underwent open resection
Morino M, Surg Endosc 2005
Laparoscopic vs. Open Surgery for Extraperitoneal Rectal Cancer
Laparoscopicn = 98
Openn = 93
P
Mean follow up (months) 46.3 49.7 NS
Conversion rate (%) 18.4
Mobilization (days) 1.7 3.3 < 0.001
Flatus (days) 2.6 3.9 < 0.001
Stool (days) 3.8 4.7 < 0.01
Oral intake (days) 3.4 4.8 < 0.001
Hospital stay (days) 11.4 13.0 NS
Morino M, Surg Endosc 2005
Laparoscopic vs. Open Surgery for Extraperitoneal Rectal Cancer
Laparoscopicn = 98
Openn = 93
P
Morbidity (%) 24.4 23.6 NS
Mortality (%) 1.0 2.2 NS
Anastomotic leakage (%) 13.5 5.1 NS
Reoperation (%) 6.1 3.2 NS
Local recurrence (%) 3.2 12.6 < 0.05
Cumulative 5-year survival rate (%) 80.0 68.9 NS
Disease-free 5-year survival rate (%) 65.4 58.9 NS
Morino M, Surg Endosc 2005
Morino M, Surg Endosc 2005
Laparoscopic vs. Open Surgery for Extraperitoneal Rectal Cancer
Conclusion
Laparoscopic resection for low and midrectal
cancer is characterized by faster recovery and
similar overall morbidity with no adverse
oncologic effect
Long – Term Results in Rectal Cancer
Lai JH, et al. Br Med Bull 2012
Conclusions
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 suggest oncological safety.
Guidelines
• NICE Guidelines
• ASCRS
NICE guidelines laparoscopic colorectal cancer - August 2006
• Laparoscopic surgery is recommended as an alternative to open surgery for colorectal cancer…..
• The surgeon has been trained in laparoscopic surgery for colorectal cancer and performs the operation often enough to keep his skills up to date
Who is competent?
SpR Training
Laparoscopic colorectal fellowships
• St Marks - R Kennedy
• Colchester - R Motson
• Leeds - PM Sagar
Preceptorship
• Training consultants
• Preceptorships - 2-4 cases
• Consultants should have seen >10 live resections– Courses– Personal visits
Preceptorships
• Preceptors - >100 cases with annual workload of >25 cases
• Audit data - NBOCAP, MDT
• Video material - aide memoire
• ( US - >20 benign cases but BEWARE…)
• www.alsgbi.org
• Conversion rate:– Right sided Lesions: 8%– Left Sided Lesions: 15%
• Independent Predictors of Conversion– BMI– ASA grade– Type of resection– Intra-abdominal abscess/fistula– Surgeon’s experience
• Learning Curve:– Right sided lesions: 55 cases– Left sided lesions: 62 Cases
• Two surgeons– 721 laparoscopic colorectal procedures
• Learning Curve: 70-80 Procedures– Operating time– Conversion rates
• http://www.youtube.com/watch?v=rOjdpdtIhBA
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