Η Λαπαροσκοπική Χειρουργική στον Καρκίνο του Παχέος...

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)

• Λαπαροσκοπική Υποβοηθούμενη Δεξιά Ημικολεκτομή - Δ.Κορκολής: Χειρουργός - YouTube

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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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