Laparoscopic Colectomy

Introduction

Since the first laparoscopic cholecystectomy was performed in 1985, advances in minimally invasive techniques and equipment have permitted safe and more advanced operations to be performed. Minimally invasive colon surgery has not been embraced with the same enthusiasm as laparoscopic cholecystectomy. Some of the concerns regarding laparoscopy were based on early reports of port site recurrence of colon cancer. Open colectomy was considered the cornerstone operation, especially for colorectal neoplasia. Compared with open colectomy, laparoscopic colectomy has been shown to be associated with decreased postoperative analgesia requirement, faster return of bowel function, earlier resumption of oral intake, shorter hospital stay, and better cosmesis. However, these benefits come at the cost of slightly prolonged operative time and associated expense. In addition, surgeons who perform these operations need more advanced laparoscopic skills and training.

• 1.
  A 55-year-old man had a 2-cm polyp with invasive cancer found during routine surveillance colonoscopy. He is worried about the risk of recurrence if a laparoscopic approach is used. Which of the following statements is true?

  1. Laparoscopic surgery is associated with a higher recurrence rate of cancer than open surgery
  2. Laparoscopic surgery should never be used for cancer; it is indicated only for benign disease
  3. The laparoscopic approach is an acceptable and safe alternative to open surgery
  4. The polyp should be resected via an endoscopic approach

Indications for Laparoscopic Colectomy

The indications for laparoscopic colectomy are essentially the same as the indications for an open procedure, and can be subgrouped into colectomy for benign disease vs neoplasia.

Benign disease: This includes inflammatory bowel disease (ulcerative colitis and Crohn's disease), diverticular disease, rectal prolapse, and colonic dysmotility.

Neoplasia: This includes polyps not amenable to colonoscopic resection, colorectal cancers, and hereditary colon cancer syndromes such as familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer (HNPCC), among others.

Several clinical trials were initiated in the 1990s to address the controversial issue of using laparoscopic surgical techniques for colorectal cancer. A brief description of 2 of these trials follows.

Clinical Outcomes of Surgical Therapy (COST) study.[1] This multi-institutional trial involved 48 centers and a total of 872 patients with colon cancer who underwent either open or laparoscopy-assisted colectomy .The median follow-up time was 4.4 years. The time to tumor recurrence was used as a primary endpoint. The rates of recurrence were 16% in the laparoscopy-assisted group vs 18% in the open-colectomy group (P = .32).This trial revealed no difference in local wound recurrence rate between the 2 patient groups (< 1%). Additionally, there was no difference in overall survival (86% for laparoscopy-assisted and 85% for open colectomies) at 3 years of follow-up. The laparoscopic group demonstrated faster recovery with shorter median hospital stay (5 days vs 6 days) and shorter use of postoperative narcotics (3 days vs 4 days). These findings demonstrated that the laparoscopic approach to treating colorectal cancer is an acceptable and safe alternative to open surgery.

COlon carcinoma Laparoscopic or Open Resection (COLOR) trial.[2] This European trial involved 27 institutions and 1248 patients randomly assigned to either laparoscopic surgery or open surgery for colon cancer. Data for cancer-free survival 3 years after surgery have not been reported yet. Patients who underwent laparoscopic resection had less blood loss compared with patients who underwent open resection (median 100 mL vs 175 mL), but median operative times were longer for the laparoscopic group (202 vs 170 minutes). Earlier recovery of bowel function, need for less analgesia, and shorter hospital length of stay were other benefits observed with laparoscopic resection. Morbidity and mortality rates 28 days after colectomy were similar among the laparoscopic and open resection groups. Additionally, resection margins, number of lymph nodes, tumor stage, tumor size, and number of reinterventions required within 28 days after surgery did not differ between treatment groups.

• 2.
  The 55-year-old patient described in question 1 wishes to proceed with resection. All of the following are associated with laparoscopic colectomy vs open colectomy except

  1. Less postoperative pain
  2. Higher morbidity and mortality
  3. Fast return of bowel function
  4. Shorter hospital stay

Potential Benefits of Laparoscopic Colectomy

Several randomized and nonrandomized trials have demonstrated the potential benefits associated with laparoscopic colectomy.

Short-Term Benefits

• Less postoperative pain: Most studies have shown a decrease in both the dose and duration of parenteral analgesia required after laparoscopic surgery. These differences are small but not insignificant.[1,3,4]

• Return of bowel function: The majority of trials show that on average, both time to flatus and bowel movement are a day earlier in laparoscopic surgery than open surgery. This also translates into earlier resumption of oral intake.[3–5]

• Shorter hospital stay: The overall hospital stay is decreased by 1 to 2 days for laparoscopic surgery for the reasons mentioned previously.[1,3,5]

• Morbidity and mortality: Three randomized trials found no No difference in morbidity and mortality between laparoscopic and open colectomy groups.[1,3,6]

• Average blood loss: This variable has not been consistently reported on across trials, with some reporting less blood loss associated with the laparoscopic-assisted procedure and others reporting no difference in blood loss for the laparoscopic approach. The reduction in blood loss reported is approximately 100 cc.[6,7]

• Cost: Data on a subset of patients (n = 682) in the CLASICC (Conventional vs Laparoscopic Assisted Surgery in patients with Colorectal Cancer) trial were analyzed.[8] The operating room costs associated with the laparoscopic approach were higher than for open colectomy. However, some of this expense was offset by reduced postoperative cost. The short-term cost analysis showed that the cost associated with laparoscopic surgery was only marginally higher than open surgery (6899 pounds vs 6631 pounds). Similarly, short-term costs were also analyzed for the COLOR trial.[9] Total costs to society did not differ significantly between laparoscopic and open colectomy groups, even though the cost of operation was significantly higher for the laparoscopic vs open approach.

Long-Term Benefits

• Margins and lymphadenectomy: There is no difference in the number of lymph nodes resected and resection margins between laparoscopic and open colectomy. In the COST trial, no difference was present in the median length of bowel margins between laparoscopic and open colectomies.[1] Similarly, the number of lymph nodes removed was also not different between the 2 approaches.[6]

• Recurrence rate: Earlier case reports and case series cited a very high rate of port site recurrence for the laparoscopic approach.[9–11] This resulted in some trepidation in embracing laparoscopic surgery for the treatment of colon cancer, but larger randomized trials did not support this finding.[1,3,6] In the COST trial, the wound recurrence rate was 0.5% for the laparoscopic group and 0.2% for the open group.[1] Local recurrence rates were also similar between the 2 groups.[1,6]

• Survival: No difference in overall survival has been observed between laparoscopic and open surgery. In the COST trial, overall survival was similar for the laparoscopic and open surgery groups at 3 years with any stage of cancer.[1] Lacy and colleagues[6] found a survival advantage in a subgroup of their patients with stage 3 colon.

• Reduced overall cost: Although long-term studies are still lacking, the faster recovery associated with the laparoscopic technique potentially translates into fewer days lost to illness, and decreased overall cost to society.[9]

• 3.
  You prescribe a polyethylene glycol bowel preparation for a patient. Which of the following is true regarding preoperative bowel cleansing for colorectal surgery?

  1. It reduces the rate of anastomotic leaks
  2. It reduces the rate of wound infections
  3. It reduces mortality from colorectal surgery
  4. It can cause serious electrolyte imbalances

Issues in Bowel Preparation

Bowel preparation before colorectal surgery is still commonly recommended and performed in many centers in the United States. Earlier patient series reported complications such as anastomotic dehiscences, intra-abdominal sepsis, and wound infection as the most common cause of postoperative mortality.[12,13] The higher rate of these complications was attributed to higher degrees of intestinal contamination. Therefore, it seemed logical to empty the colon of its contents to reduce the rate of these complications.

Current clinical data offer no evidence to support the claim that preoperative colon cleansing reduces the risk of anastomotic leaks or infectious complications.[14] On the contrary, doing so may increase the rate of anastomotic complications. Despite this, 99% of surgeons still use some form of bowel preparation for patients undergoing colorectal surgery.[15] Also of note is that bowel cleansing can have potential side effects, such as electrolyte imbalances, dehydration, patient discomfort, and there is an associated cost. Some elderly and fragile patients may need to be admitted to the hospital for the bowel preparation – further adding to costs and hospital length of stay. Some clinicians have also reported slower return of bowel function after preoperative bowel cleansing (3.9 vs 2.5 days).[16] However, during laparoscopy, preoperative bowel preparation is used by many surgeons because it adds to the ease of bowel handling and potentially reduces operative time. Because laparoscopy makes palpation of colorectal lesions very difficult, a clean colon can aid in identification of a lesion.

Laparoscopic Colectomy: Basic Operative Principles

1. Dissection in bloodless planes

2. Proximal vessel ligation

3. Adequate margins

4. Adequate lymphadenectomy

5. Appropriate training and skills of surgeon

Dissection in anatomic planes avoids unnecessary bleeding problems and minimizes the blind use of electrocautery. The goals of laparoscopic colectomy are the same as for open surgery. Laparoscopic colon surgery requires a higher degree of special dexterity and technical skills. An initial training period is usually required to become proficient in these procedures. The learning curve in laparoscopic colectomy ranges from 30 to 70 cases. This refers to acquisition of skills necessary to completely eliminate “failure” or reduce it to a minimum. The primary components of the learning curve, with conversion being the end point, are training and experience of the surgeon, presence of inflammatory reaction in the operative field, type of colectomy (right vs left), and body mass index of the patient. Patient outcomes depend more on advanced laparoscopic skills of surgeons and adherence to accepted oncologic surgical principles (in cases of malignancy), than on the size or location of the healthcare institution.

Operation

Video clip: Laparoscopic Right Hemicolectomy – Click "Play" to view the video.

Once the colon is fully mobilized, it becomes a midline structure such that any specimen can be easily retrieved via an umbilical incision.

Download video file ^{(13.7MB, wmv)}

Right colectomy. The procedure is performed with the patient under general endotracheal anesthesia. The patient is positioned supine and pneumoperitoneum is established either via Veress needle or open Hassan trocar approach. A supraumbilical 10/12-mm port is inserted. Two additional 5-mm ports are placed, one in upper midline or slightly to right of midline and the other in left lower quadrant. The patient is placed in the Trendlenburg position and the peritoneum along the cecum and terminal ileum is scored with electrocautery. This dissection is carried cephalad along the ascending colon, identifying and preserving the ureter. Dividing the peritoneal attachment along the terminal ileum facilitates exteriorization of bowel. To mobilize the hepatic flexure, the patient is placed in reverse Trendlenburg and the gastrocolic ligament is taken down with a combination of electrocautery and ultrasonic shears. Care should be taken to properly identify the duodenum at this point to avoid causing injury to it. Once the bowel is sufficiently mobilized, one of the port sites is enlarged and the bowel exteriorized. The specimen is resected and anastomosis performed extracorporeally. The bowel is then returned back to the peritoneal cavity, and the fascial defect closed.

Left colectomy. The patient is placed in a lithotomy position and a 5-mm supraumbilical port is placed. Pneumoperitoneum is established, and 2 additional 5-mm ports are placed in the suprapubic midline and left lower quadrant. Another 10/12-mm port is placed in the right lower quadrant. The patient is then placed in Trendlenburg position and peritoneal attachments scored along the white line of Toldt. The left ureter is identified to prevent injury to it. The patient is then placed in reverse Trendlenburg position to mobilize the splenic flexure. The omentum is dissected off the colon in the bloodless plane using electrocautery. Once the splenic flexure is mobilized, the patient is placed again in the Trendlenburg position. The pararectal peritoneum is scored on either side to the desired level of rectal transaction. The vascular pedicle is divided by ultrasonic shears or vascular stapling device. Similarly, the rectum is also divided with a linear vascular stapler. The suprapubic port site incision is enlarged and the bowel exteriorized through that. The specimen is then removed by stapling the proximal end of the bowel. The anvil of circular stapling device is placed into the proximal bowel and purse-string sutures placed around it. The bowel is then returned to the peritoneal cavity. At this point, an anastomosis can be constructed by inserting the circular stapling device through the anus and performing the anastomosis. Alternatively, a hand-sewn or stapled anastomosis can be performed as well. Rigid sigmoidoscopy is performed with anastomosis under water to rule out any leaks. A drain is not routinely placed.

Complications

The postoperative complications associated with laparoscopic colorectal surgery are essentially the same as those for open surgery. Certain other complications, such as port site hernia, are specific to the laparoscopic approach. The overall rate of complications is approximately 9%. Ileus and small bowel obstruction, both operative and nonoperative, are the most common causes for readmission (in about 4% of cases). Abdominal abscess and anastomotic leak occur in 1.1% and 0.7% of cases, respectively. Other complications include fever, dehydration, pulmonary embolus, wound infection, and cardiac arrhythmias. Internal hernias, although commonly reported with other minimally invasive procedures such as Roux-en-Y gastric bypass, are a rare occurrence after laparoscopic colectomy.[17]