Laparoscopic Colorectal Surgery

 

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In early 1990s, laparoscopic colectomy was an evolving technique whose oncologic safety had not been proved. Initial case reports describing port-site metastasis as a complication of laparoscopic surgery for cancer caused fantastic alarm, with early reports in small case series noting metastasis rates up to 21%.

Numerous surgeons questioned whether there was a novel risk for tumor cell dissemination during laparoscopy compared to open, or conventional, surgery. Proposed mechanisms included cancer cell implantation during the release of pneumoperitoneum, direct tumor implantation from the contaminated instrument or during extraction from the specimen via a small incision, stimulation of tumor growth by the insufflating gas, and also the laparoscopic method itself.

Döbrönte et al first described port-site metastasis in 1978 after an ovarian cancer operation. Although the underlying etiology continues to be unclear, the introduction of recurrent cancer in a previous surgical site is not unique to laparoscopic surgery but occurs after open surgery as well. Two retrospective reviews of open colectomy for colorectal cancer, each with more than 1500 patients, demonstrated an incidence of 0.6% to 0.68% of incisional tumors, with overall abdominal wall tumors through an incidence of 1%. Multiple studies have now demonstrated that the incidence of port-site metastasis after laparoscopic surgery is low.

A prospective evaluation by the Laparoscopic Bowel Surgery Registry, which was initiated in 1992 by the American Society of Colon and Rectal Surgeons, the American College of Surgeons, and also the Society of yankee Gastrointestinal Endoscopic Surgeons, reported the rate of the complication to be at 1.1%, like the results for open surgery. Recent trials evaluating the outcome of laparoscopic colectomy for cancer also have reported a similarly low incidence of port-site metastasis.

Today these operations are performed with very little thought of this now historical concern. However, it was only following the publication of the set of the Clinical Outcomes of Surgical Therapy (COST) Study Group1 trial in 2004 that laparoscopic surgery became an accepted practice in the management of colorectal cancer. Using the publication of several multi-institutional, prospective randomized trials, it became clear that laparoscopic colectomy is equivalent to open colectomy in terms of oncologic safety for all stages of colon cancer.

Margins of resection, number of lymph nodes harvested, cancer-related survival rates, and rates of complications and mortality are identical whether the operation is performed open or laparoscopically.

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