Laparoscopy in colorectal surgery: a call for careful appraisal

Laparoscopic gastric mobilization in postcricoid cancer surgery

AIM

Postcricoid cancer is an aggressive neoplasm that presents specific therapeutic problems. This study compares laparoscopic stomach mobilization following total pharyngolaryngoesophagectomy (TPLE) with open mobilization following TPLE with respect to postoperative recovery, perioperative morbidity, and mortality.

SUBJECTS AND METHODS

This is a retrospective study in a contemporary series of patients with resectable postcricoid cancer from a single institute (Gujarat Cancer & Research Institute, M.P. Shah Cancer Hospital, Ahmedabad, Gujarat, India). Twenty-five consecutive patients who underwent laparoscopic TPLE were compared with 40 patients who underwent open TPLE from January 2006 to December 2010.

RESULTS

Laparoscopic and open TPLE procedures were compared with respect to patient demographics, operative information (blood loss, duration), and complications. The mean duration of surgery was 3.5 hours in the laparoscopic group and 5.5 hours in the open group. The respective mean blood loss was 290 mL and 460 mL. The respective mean time to full oral intake was 10 days and 11 days. The respective average duration of hospitalization was 13 days and 17 days. In the laparoscopic group, 3 (12%) and 4 (16%) patients had pneumonic consolidation and wound infection, respectively, compared with 8 (20%) and 8 (20%) patients in the open group. In the laparoscopic group, there were two (8%) perioperative deaths, compared with four (10%) in the open group.

CONCLUSIONS

Laparoscopic TPLE is safe with less morbidity and mortality and quicker postoperative recovery compared with open surgery.

Use of intrathecal morphine for postoperative pain relief after elective laparoscopic colorectal surgery

Laparoscopic surgery has become popular in recent years, but few studies have addressed analgesia for this type of surgery. We conducted a prospective double-blind randomised trial on 36 cases of laparoscopic colorectal surgery to determine the influence of intrathecal morphine on postoperative pain relief. All patients received a subarachnoid block with local anaesthetic in addition to general anaesthesia. One group also received intrathecal morphine. A patient-controlled analgesic (PCA) device was prescribed for pain control postoperatively and the visual analogue score (VAS) was used for pain assessment. The group who received intrathecal morphine used significantly less morphine. There were no adverse cardiovascular effects of the combined anaesthetic technique. Nausea and vomiting remained the main side-effect of intrathecal morphine but this was easily treated with anti-emetics.

Laparoscopic colectomy vs. open colectomy for sigmoid diverticular disease

PURPOSE

The feasibility of laparoscopic colectomy for colon surgery has now been well established. Most of the studies on laparoscopic colectomies include all types of colonic pathologies without discrimination. Our goal was to compare laparoscopic sigmoid colectomy open sigmoid colectomy for simple sigmoid diverticular disease, to assess whether it can be done safely and whether the proposed advantages could be realized.

METHODS

We evaluated the differences in outcomes of 66 laparoscopic sigmoid colectomy patients and 88 open sigmoid colectomy patients. We report a five-year outcomes analysis of 154 patients undergoing sigmoid colectomy for diverticular disease. We compared age, gender, history of prior abdominal surgery, estimated blood loss, operative time, total conversions with reason for conversion, time until a liquid diet was started, postoperative complications, hospital length of stay, operation costs, and total hospital charges incurred for both laparoscopic sigmoid colectomy and open sigmoid colectomy.

RESULTS

Mean age and gender were similar in the two groups. However, the mean estimated blood loss (143 ml 314 ml), time until a liquid diet was started (2.9 4.9 days), and hospital length of stay (4.8 8.8 days) were all significantly less in laparoscopic sigmoid colectomy patients. The mean operative time for laparoscopic sigmoid colectomy was 212 minutes as compared with 143 minutes for open sigmoid colectomy ( < 0.05). Conversion rate of laparoscopic sigmoid colectomy to open procedure was 19.7 percent. All laparoscopic sigmoid colectomy patients received a lighted ureteral stent preoperatively, which was removed at the end of surgery. Relevant complications for laparoscopic sigmoid colectomy open sigmoid colectomy were as follows: anastomotic leak in 1 3 (1.5 3.4 percent) patients, hematuria in 64 6 (97 6.8 percent) patients, with an average duration for 2.93 3 days, urinary tract infection in 5 4 (7.6 4.5 percent) patients, and ureteral injury in 1 2 (1.5 2.2 percent) patients. Although the mean operating room charges were greater in the laparoscopic sigmoid colectomy patients ($9,566 $7,306) the mean hospital charges ($13,953 $14,863) were less.

CONCLUSIONS

We recommend laparoscopic sigmoid colectomy as the modality of treatment for diverticular disease. Laparoscopic sigmoid colectomy seems to be a reliable, safe and efficacious treatment modality with better outcomes for diverticular disease of the sigmoid colon. The operative time for laparoscopic sigmoid colectomy is decreasing as surgeons gain more experience.

Harmonic scalpel in laparoscopic colorectal surgery

PURPOSE

With advances in laparoscopy, various hemostatic procedures have been advocated with variable results. Using currently available tools, some steps in laparoscopic colorectal surgery still represent technical challenges. Our aim was to investigate the feasibility and reliability of the Harmonic Scalpel in laparoscopic colorectal surgery.

METHODS

In this nonrandomized prospective study, 34 consecutive patients (15 males; mean age, 46 (range, 24-80) years) underwent laparoscopic colorectal surgery for benign disease (27 patients) and colorectal cancer (7 patients). Dissection, hemostasis, coagulation, and division of several types of vascular pedicles were performed exclusively with the Harmonic Scalpel. The 10-mm-blade Harmonic Scalpel device was used at full power mode for all purposes through a 10-mm port. Coagulation of vascular pedicles was always achieved with the blades in the flat position. The large pedicles (inferior mesenteric, right and left colic, and ileocolic) were coagulated for 20 seconds in several locations along the length (1 cm) before final division. Smaller vascular pedicles were coagulated for ten seconds before division. When the vein and the artery of major pedicles were divided at their origin, either for malignancy or for technical reasons, they were dissected and coagulated separately. For more limited resection of the mesentery, as in the case of benign disease, vascular pedicles were coagulated together as a single bundle. Operative time, minor or major intraoperative or postoperative hemorrhage, need for conversion to laparotomy, bowel injury, and trocar complications were recorded. All anastomoses were checked on Day 8 by a diatrizoate sodium enema.

RESULTS

There was no mortality. Mean operative time was 276 (range, 200-520) minutes. Neither minor nor uncontrollable hemorrhage occurred; no conversion to laparotomy and no vascular or bowel injury were recorded. There was one port-site hematoma. Neither hemoperitoneum, intraperitoneal hematoma, fistula, nor intra-abdominal abscess was observed.

CONCLUSION

Coagulation and division of minor as well as major vascular pedicles in laparoscopic colorectal surgery with the Harmonic Scalpel" are technically easy, feasible, and reliable.

Laparoscopic total mesorectal excision with autonomic nerve preservation

Laparoscopy has greatly influenced abdominal surgery. We hypothesize that the benefits of minimally invasive surgery are applicable to rectal cancer. A cadaver model of laparoscopic rectal resection with total mesorectal excision (TME) and autonomic nerve preservation was utilized to explore this hypothesis. The principles of TME were followed, including high vascular ligation, sharp mesorectal dissection, and identification and preservation of the autonomic pelvic nerves. After proving feasibility in the cadaver model, a clinical study was performed on patients with mid to low rectal cancers. We observed acceptable morbidity with this minimally invasive technique of rectal resection and TME. We conclude that there is growing evidence that laparoscopic methods can be applied to patients with rectal cancer.

Laparoscopic ultrasound for the detection of hepatic metastases during laparoscopic colorectal cancer surgery

PURPOSE

The search for liver metastases before surgery forms an accepted part of colorectal cancer surgical practice. Intraoperative ultrasound and manual palpation of liver together form the criterion standard as far as screening for metastases is concerned. However, extracorporeal imaging, such as ultrasound and magnetic resonance imaging, are also widely used. The purpose of this study was to demonstrate the efficacy of laparoscopic ultrasound scan in detection of liver metastases during laparoscopic colorectal cancer surgery by comparison with conventional imaging modalities.

METHODS

A prospective, controlled study was undertaken. A total of 76 consecutive patients undergoing laparoscopic colorectal resections for malignancy were recruited. Patients underwent preoperative liver ultrasound scan and intraoperative blinded laparoscopic ultrasound scan examination performed by a single surgeon. Contrast-enhanced magnetic resonance imaging was performed within 30 days of surgery.

RESULTS

Conventional ultrasound scan was negative in all cases. Metastases were identified during simple laparoscopic inspection of the liver in one case. Two cases shown by laparoscopic ultrasound scan to have definite metastases were confirmed by magnetic resonance imaging. In seven further instances laparoscopic ultrasound scan identified suspicious liver masses. In three cases these were confirmed to be metastases at magnetic resonance imaging; one was confirmed as a cyst, and the remaining three suspicious lesions were confirmed at serial magnetic resonance imaging scans to be benign and of no significance.

CONCLUSION

Laparoscopic ultrasound scan with a flexible-tipped probe permits satisfactory hepatic examination. It is superior to conventional ultrasound scan and seems to be as effective as magnetic resonance imaging, although the latter modality is still required to delineate identified lesions.

Laparoscopic colectomy

Laparoscopic treatments for benign colonic disease and as palliative operations for advanced malignant disease have gained widespread acceptance as safe, efficacious, and beneficial treatment options. There are also strong indications that laparoscopic treatment for malignant colorectal disease is a viable alternative in selective patients. Further studies with substantial follow-up to determine the adequacy of resection and the comparability of cure rates are needed to assess any changes in the long-term staging and survival patterns of these treatments.

Laparoscopically assisted total laryngopharyngoesophagectomy with gastric transposition

Pharyngolaryngoesophagectomy (PLO) for post-cricoid tumour offers opportunity for cure or reasonable paliation. However, it carries significant morbidity and mortality. We present two patients with post-cricoid carcinomas who underwent laparoscopically-assisted total PLO with gastric transposition without a laparotomy, thoracotomy or thoracoscopy. This technique appears promising for patients with post-cricoid or hypopharyngeal malignancy in reducing operative morbidity, and may represent improvement on conventional open and thoracoscopic techniques in selected patients.

Intraperitoneal cell movement during abdominal carbon dioxide insufflation and laparoscopy. An in vivo model

PURPOSE

Possible mechanisms of movement of malignant cells within the peritoneal cavity during CO2 insufflation and laparoscopy involve direct transfer via laparoscopic instruments or dispersion of cells by CO2 or water vapor. An in vivo model has been developed to study these mechanisms.

METHODS

Laparoscopy was performed on an animal model (domestic white pig). Cells derived from colorectal cancer cell line Lim 1215 were injected to lie free within the peritoneal cavity. A polycarbonate filter system with a 5-micron pore diameter was used to examine CO2 expelled from the peritoneal cavity, during laparoscopy and manipulation of abdominal viscera, for malignant cells. Laparoscopic instruments and laparoscopic ports were washed independently, and fluid was centrifuged and examined for malignant cells.

RESULTS

Malignant cells were identified on 1 of 30 filters used to examine exhaust carbon dioxide. Malignant cells also were identified from 2 of 10 washings from laparoscopic ports and from 4 of 10 washings of laparoscopic instruments.

CONCLUSIONS

These results suggest that movement of cells throughout the peritoneal cavity during laparoscopy is via contaminated instruments, but local cell movement by dispersion possibly within water vapor from the port may also occur.