Impact of pneumoperitoneum on trocar site implantation of colon cancer in hamster model

Factors influencing the application of transrectal natural orifice specimen extraction performed laparoscopically for colorectal cancer: A retrospective study

BACKGROUND

A few factors influence the feasibility of transrectal natural orifice specimen extraction (NOSE) surgery for colorectal cancers. However, little is known about the underlying factors of NOSE surgery.

METHODS

Consecutive patients with rectal and sigmoid colon cancers treated laparoscopically between January 2014 and April 2017 were enrolled in this study. The transrectal NOSE performed laparoscopically was the first choice of all patients. When NOSE failed, the specimen was removed through a midline abdominal wall incision. Univariate and multivariate logistic regression analyses were performed to identify challenging factors influencing the intraoperative specimen extraction.

RESULTS

Overall, 412 consecutive patients were included. NOSE performed laparoscopically was successful in 278 patients (75.5%) and unsuccessful in 90 patients (24.5%). The multivariate analyses indicated that body mass index (BMI; odds ratio [OR] = 3.510, 95% confidence interval [CI]: 1.333-9.243, p = 0.011), mesenteric thickness (OR = 1.069, 95% CI: 1.032-1.107, p < 0.001), maximum tumor diameter (OR = 2.827, 95% CI: 1.094-7.302, p = 0.032), and tumor T stage (OR = 2.831, 95% CI: 1.258-6.369, p = 0.012) were the factors influencing the feasibility of NOSE surgery.

CONCLUSION

A successful transrectal NOSE surgery was associated with a lower BMI, thinner mesentery, lesser tumor diameter, and earlier tumor T stage.

Incidence of Port Site Metastasis in Laparoscopic Radical Nephroureterectomy: Single-institution Experience

OBJECTIVE

To address the incidence and potential risk factors of port site metastasis (PSM) in patients who underwent laparoscopic radical nephroureterectomy (RNU) for upper tract urothelial carcinoma.

MATERIALS AND METHODS

Between January 2013 and December 2018 laparoscopic RNU were performed in 240 patients at our institution, including 145 with renal pelvic tumor and 135 with ureteral tumor (40 patients have both tumor). Laparoscopies were performed through the transperitoneal approach in 28 patients, and retroperitoneal in 212 patients. Clinical data are retrospectively collected.

RESULTS

Perioperative and pathologic data are available in all 240 cases. After a mean follow-up of 12.6 months (range 3-45 months), 4 patients (1.7%) developed PSM following retroperitoneal RNU at an average of 4.3 months. Tumor stage is T2N0M0 in one, T3N0M0 in two, and T3N1M0 in one, respectively. Tumor grade are high-grade urothelial carcinoma in all. The incidence of PSM is 2.8% (4/145) and 0.7% (1/135) in renal pelvic and ureteral tumor, respectively.

CONCLUSION

We report a 1.7% incidence of PSM in upper tract urothelial carcinoma after laparoscopic RNU. We suggest that air leakage during retroperitoneal approach, high tumor stage (pT3) and grade, and advanced renal pelvic tumor with micrometastases could increase the potential risks of PSM.

Warmed, humidified CO2 insufflation benefits intraoperative core temperature during laparoscopic surgery: A meta-analysis

BACKGROUND

Intraoperative hypothermia is linked to postoperative adverse events. The use of warmed, humidified CO₂ to establish pneumoperitoneum during laparoscopy has been associated with reduced incidence of intraoperative hypothermia. However, the small number and variable quality of published studies have caused uncertainty about the potential benefit of this therapy. This meta-analysis was conducted to specifically evaluate the effects of warmed, humidified CO₂ during laparoscopy.

METHODS

An electronic database search identified randomized controlled trials performed on adults who underwent laparoscopic abdominal surgery under general anesthesia with either warmed, humidified CO₂ or cold, dry CO₂ . The main outcome measure of interest was change in intraoperative core body temperature.

RESULTS

The database search identified 320 studies as potentially relevant, and of these, 13 met the inclusion criteria and were included in the analysis. During laparoscopic surgery, use of warmed, humidified CO₂ is associated with a significant increase in intraoperative core temperature (mean temperature change, 0.3°C), when compared with cold, dry CO₂ insufflation_. CONCLUSION: Warmed, humidified CO₂ insufflation during laparoscopic abdominal surgery has been demonstrated to improve intraoperative maintenance of normothermia when compared with cold, dry CO_2.

Minimally invasive surgery in the management of abdominal tumors in children

The application of minimally invasive surgical techniques to pediatric abdominal tumors is a controversial application towards the surgical management of childhood cancer. Although general pediatric surgeons practice minimally invasive surgery techniques in a vast array of abdominal cases, its role in pediatric oncology is still developing, with no consensus in North America about its use for pediatric solid abdominal tumors. The purposes of this article are to review the current literature about the use of minimally invasive surgery in pediatric abdominal oncology and to examine established indications, procedures and technologic advances.

Does carbon dioxide pneumoperitoneum enhance wound metastases following laparoscopic abdominal tumor surgery? A meta-analysis of 20 randomized control studies

The mechanisms involved in the development of wound metastasis following laparoscopic abdominal tumor surgery remain unclear. The aim of this study was to accurately assess whether the duration of carbon dioxide pneumoperitoneum (CDP) during laparoscopic abdominal tumor surgery enhances wound metastases. We conducted a systematic review of PubMed, Cochrane Library, and Embase through December 2013 to identify animal experiments comparing wound recurrence between laparoscopic and gasless laparoscopic procedures or open procedures. The outcome of interest was the number of animals with a wound tumor. Meta-regression was used to assess whether heterogeneity was explained by study level covariates (animal model, study size, CDP pressure, duration, and evaluated time). Twenty randomized control studies involving 1,229 animals were included. Wound recurrence was not significant in the laparoscopic surgery (LP) vs. gasless laparoscopic surgery (GLP) subgroups [odds ratio (OR), 2.23; 95 % confidence interval (CI), 0.90-5.55; P = 0.08) or the LP vs. laparotomy (LA) subgroups (OR, 0.97; 95 % CI, 0.31-3.00; P = 0.08). Overall postoperative wound recurrence results were not significantly different between the study groups and controls (OR, 1.47; 95 % CI, 0.74-2.92; P = 0.28). A meta-regression analysis showed that the outcome was not correlated with the covariates (animal model: P = 0.82; evaluated time: P = 0.30; pressure of CDP: P = 0.12; duration time: P = 0.80). Current evidence suggests that CDP does not enhance wound metastases following laparoscopic abdominal tumor surgery. Additional large sample, well-designed, randomized, controlled trials are needed to further confirm whether CDP duration in laparoscopic abdominal tumor surgery significantly enhances wound recurrence.

Stimuli-induced organ-specific injury enhancement of organotropic metastasis in a spatiotemporal regulation

The relationship between inflammation and tumorigenesis has been established. Recently, inflammation is also reported to be a drive force for cancer metastasis. Further evidences show that various stimuli directly induced-injury in a specific organ can also promote metastasis in this organ, which include epidemiological reports, clinical series and experimental studies. Each type of cancer has preferential sites for metastasis, which is also due to inflammatory factors that are released by primary cancer to act on these sites and indirectly induce injuries on them. Host factors such as stress,fever can also influence distant metastasis in a specific site through stimulation of immune and inflammatory effects. The five aspects support an idea that specific-organ injury directly induced by various stimuli or indirectly induced by primary tumor or host factors activation of proinflammatory modulators can promote metastasis in this organ through a spatiotemporal regulation, which has important implications for personalized prediction, prevention and management of cancer metastasis.

Camera-port site metastasis of a renal-cell carcinoma after robot-assisted partial nephrectomy

BACKGROUND AND PURPOSE

Port-site metastasis (PSM) is a rare complication of laparoscopic intervention in urologic malignancies. Of the greater than 50 reported cases of PSM in the urologic oncology literature, only 9 have occurred after surgery for renal-cell carcinoma (RCC). We report a 10th instance of RCC metastasis-in this case to the camera-port site after robot-assisted partial nephrectomy (RAPN). To our knowledge, this case is the first reported PSM of RCC after RAPN.

PATIENT AND METHODS

A 68-year-old man underwent an uncomplicated right RAPN for a 4-cm right renal mass (stage T1aN0M0). Five months later, he was found to have metastatic disease with an isolated peritoneal recurrence at the camera-port site. Biopsy of the lesion confirmed RCC, and the lesion was surgically resected. A comprehensive MEDLINE search for all published studies of port-site recurrences after laparoscopic renal surgery for RCC was performed.

RESULTS

Nine cases of PSM after successful laparoscopic radical or partial nephrectomy for locally confined RCC have been reported. Proposed etiologic factors for port-site recurrence include biologic aggressiveness of the tumor, patient immunosuppression, local wound factors, and technique-related factors. We report an unusual case of PSM to a camera port that was not used for specimen manipulation or extraction.

CONCLUSION

PSM after laparoscopic renal surgery for RCC is a rare occurrence. Our case, in which PSM occurred without specimen bag rupture or extraction through the port in question, highlights the importance of local and systemic factors in contributing to PSM occurrence. We also demonstrate that when PSM is the only site of disease recurrence, it can be successfully managed with minimally invasive surgical resection.

Laparoscopic colorectomy for colorectal cancer: retrospective analysis of 889 patients in a single center

Laparoscopic colectomy has been reported as an alternative for treatment of colorectal cancer. However, its long-term efficacy and safety remain obscure. The purpose here was to review our experience with laparoscopic colectomy in 899 patients between June 2001 and December 2008. Of them, 43 patients were converted to open surgery and 846 accepted laparoscopic colorectomy successfully. Among these 846 patients, 790 patients underwent radical resection and 56 patients underwent palliative resection. Only 1 patient died from perioperative pulmonary infection; thus the mortality was 0.12% (1/846). The morbidity of perioperative complications was 18.20% (154/846): intraoperative complication rate was 4.49% (38/846) and the most common intraoperative complication was subcutaneous emphysema and hypercapnia (1.65%, 14/846); postoperative complication rate was 13.71% (116/846) and the most common postoperative complication was ileus (4.37%, 37/846). The overall followed-up rate was 86.41% (731/846, 680 for radical operations and 51 palliative operations). Postoperative deaths happened to 139 patients, including 112 after radical operation and 27 after palliative resection. Of these 112 patients, 97 deaths were cancer-related (14.26%, 97/680) and 15 deaths were non-cancer-related. There were 10 patients encountered local recurrence (1.47%, 10/680) and 105 for metastasis (15.44%, 105/680) after radical operation. Forty-two patients are still alive with tumor. Overall survival rate was 80.98% (592/731), 3-year disease-free survival (DFS) rate after radical operation was 78.0%, and 3-year DFS rate after radical operation for stage I, stage II, and stage III was 89.0%, 85.0%, and 65.0%, respectively. In conclusion, laparoscopic colorectal resection is a feasible and safe technology for colorectal cancer.

Is port site metastasis a result of systemic involvement?

Aims:

Port site metastasis (PSM) is an unwelcome consequence of laparoscopy for oncological procedures with uncertain etiology. We present the clinical evidence to prove that PSM is likely to be due to the hematogenous spread of tumor cells.

Materials and Methods:

Six cases of port site metastasis, four following laparoscopic radical nephrectomy for localized renal cell carcinoma (RCC), one after laparoscopic radical prostatectomy done in two patients and one after laparoscopic partial cystectomy for tumor at bladder dome done in two were studied. One case of metastatic RCC with bilateral gluteal masses and two cases of open radical nephrectomy, with recurrence at the drain and incision site were also studied.

Results:

During the median follow up of 59 months (range 24–120), 4/136 patients with RCC (1.47%) developed port site metastasis between 7–36 months after surgery. All six cases of PSM had advanced disease and recurrences at other sites, that is, peritoneum, omentum, bones, and lungs. None of the patients had isolated PSM. One patient of metastatic RCC, who did not have any intervention but repeated intramuscular injections of analgesics-developed bilateral gluteal masses, confirmed to be RCC on fine needle aspiration cytology. Two patients had metastasis at the incision site (one at the drain site) with distance, including cutaneous metastases.

Conclusions:

Port site metastasis did not develop in isolation. There could be a likely existence of circulating tumor cells at the time of surgical trauma of penetrating nature, that is, port site or injection site, which manifest in some patients depending upon their immune response.

Canadian Association of University Surgeons' Annual Symposium. Surgical simulation: the solution to safe training or a promise unfulfilled?

At its 2009 annual symposium, chaired by Dr. William (Bill) Pollett, the Canadian Association of University Surgeons brought together speakers with expertise in surgery and medical education to discuss the role of surgical simulation for improving surgical training and safety. Dr. Daniel Jones, of Harvard University and the 2009 Charles Tator Lecturer, highlighted how simulation has been used to teach advanced laparoscopic surgery. He also outlined how the American College of Surgeons is moving toward competency assessments as a requirement before surgeons are permitted to perform laparoscopic surgery on patients. Dr. Teodor Grantcharov, from the University of Toronto, highlighted the role of virtual reality simulators in laparoscopic surgery as well as box trainers. Dr. Peter Brindley from the University of Alberta, although a strong proponent of simulation, cautioned against an overzealous adoption without addressing its current limitations. He also emphasized simulation's value in team training and crisis resource management training. Dr. Chris de Gara, also from the University of Alberta, questioned to what extent simulators should be used to determine competency. He raised concerns that if technical skills are learned in isolation, they may become "decontextualized," and therefore simulation might become counterproductive. He outlined how oversimplification can have an "enchanting" effect, including a false sense of security. As a result, simulation must be used appropriately and along the entire education continuum. Furthermore, far more needs to be done to realize its role in surgical safety.

Laparoscopic versus open colorectal resection for cancer: a meta-analysis of results of randomized controlled trials on recurrence

AIMS

Laparoscopic resection for colorectal cancer remains controversial. This is because it is uncertain whether recurrence rates after laparoscopic-assisted surgery is comparable to those reported after open surgery. We performed a meta-analysis of the published literature in an attempt to answer this question.

METHODS

Eligible articles were identified by searches of MEDLINE, EMBase and the Cochrane database. Prospective randomized clinical trials were eligible if they included patients with colorectal cancer treated by laparoscopic surgery versus open surgery and followed for recurrence.

RESULTS

Ten trials with information on disease recurrence on 2474 patients were included. In the combined results, no statistically significant difference in the OR for overall recurrence between the laparoscopic surgery and open surgery group was found (OR 0.93, 95% CI 0.71-1.21, P=0.58). Stratified by recurrence type, the combined results of the individual reports show no statistically significant difference for local recurrence (OR 0.80, 95% CI 0.50-1.29, P=0.36), distant metastases (OR 0.90, 95% CI 0.62-1.29, P=0.56) and port or wound-site recurrence (OR 1.04, 95% CI 0.18-6.03, P=0.97) between the two surgical techniques.

CONCLUSION

This meta-analysis supports that the recurrence rates for patients with colorectal cancer treated by laparoscopic surgery do not differ from those for open surgery. Longer follow-up studies will further define outcomes, comparing the two techniques in the treatment of colorectal cancer.

Port-Site Recurrence After Laparoscopy-Assisted Gastrectomy: Report of the First Case

In advanced gastric cancer, laparoscopic management has been associated with trocar-site recurrence, even though laparoscopy-assisted gastrectomies have reported positive results to treat early-stage gastric cancer in the world. There are no reports of port-site recurrence after laparoscopic gastrectomy in the literature. In this paper, we present a case report of advanced gastric cancer with port-site recurrence 12 month after the initial operation. A wide excision of this recurrence was performed. Otherwise, the evaluation of metastasis in other sites remained negative at 18 months after the original operation. The laparoscopic surgeon should be aware of trocar-site recurrence when dealing with advanced gastric cancer.

Is carbon dioxide insufflation safe for laparoscopic surgery? A model to assess the effects of carbon dioxide on transitional-cell carcinoma growth, apoptosis, and necrosis

PURPOSE

To study the effects of carbon dioxide insufflation pressure and concentration on the adhesion, growth, apoptosis, and necrosis of transitional-cell carcinoma (TCC).

MATERIALS AND METHODS

Adhesion and growth of the AY-27 rat TCC cell line was measured after CO2 insufflation in vitro at different pressures ranging from 0 to 15 mm Hg and after incubation in CO2-air mixtures at 5%, 10%, and 15% CO2 by volume.

RESULTS

Tumor adhesion decreased significantly after CO2 insufflation. For all insufflation pressures, there was an increase in cell growth, apoptosis, and necrosis for the first 24 hours followed by a steady decline. High concentrations of CO2 (>5%) inhibited cell growth for only the first 48 hours. The effects of CO2 pneumoperitoneum on tumor-cell adhesion, growth inhibition, apoptosis, and necrosis were more prominent at high CO2 pressure (> or =15 mm Hg) and concentration (>5% CO2). However, insufflation pressure had a greater inhibitory effect on tumor growth than did CO2 concentration. High insufflation pressures and CO2 concentrations significantly decreased extracellular pH.

CONCLUSION

The short-term effect of CO2 on TCC growth and apoptosis is complex. Overall, CO2 has a toxic effect on TCC and inhibits cell adhesion and growth. High CO2 concentrations (>5%) and high insufflation pressures (> or =15 mm Hg) are most effective in decreasing tumor-cell adhesion and growth.

Laparoscopic splenectomy in patients with inflammatory pseudotumor of the spleen: Report of 2 cases and review of the literature

We report 2 cases of splenic inflammatory pseudotumor treated by laparoscopic splenectomy. The first patient was a 58-year-old woman who complained of constipation. Computed tomography (CT) showed a well-demarcated mass that measured 4 cm in diameter and was not enhanced. She underwent laparoscopic splenectomy under a preoperative diagnosis of hemangioma. The final histopathologic diagnosis was inflammatory pseudotumor. The second patient was a 29-year-old man who complained of abdominal pain. Computed tomography revealed a demarcated splenic tumor that measured 3 cm in diameter and was not enhanced. Laparoscopic splenectomy was performed. The pathologic and operative diagnoses were both inflammatory pseudotumor. In both cases, the postoperative course was uneventful, and the postoperative hospital stays were 10 and 11 days. Preoperative diagnosis of a splenic inflammatory pseudotumor is very difficult. However, laparoscopic splenectomy is safe and beneficial treatment for this tumor and should be performed in cases in which it is diagnosed.

Portal site metastasis of invasive mesothelioma after diagnostic thoracoscopy in a dog

CASE DESCRIPTION

A 10-year-old Golden Retriever evaluated because of recurrent pericardial and pleural effusion underwent thoracoscopy with biopsy of the pleura and mediastinum.

CLINICAL FINDINGS

Before thoracoscopy, 5 L of serosanguinous fluid was removed from the pleural cavity via thoracocentesis. During thoracoscopic exploration, it was observed that the parietal pleura and mediastinum were covered by miliary white to tan nodules 1 to 3 mm in diameter. Biopsy specimens were obtained, and partial pericardiectomy was performed. Portal sites were closed routinely. Cytologic evaluation of the pleural fluid revealed high protein concentration and cellularity, with cellular changes consistent with an exfoliating carcinoma. Results of bacterial culture were negative.

TREATMENT AND OUTCOME

Carboplatin was administered via intracavitary instillation, and prednisone was administered orally. Twenty-one days later, 1 firm, irregularly shaped 6.5 x 3-cm mass and 4 smaller masses were detected in the area of the left thoracic wall where the cannula had been inserted during thoracoscopy. Histologic analysis of tissue from the masses collected at necropsy confirmed that they were malignant tumors with similar appearance to the pleural mesothelioma and immunohistochemical staining properties identical to those of the primary tumor.

CLINICAL RELEVANCE

Although thoracoscopy is associated with less postoperative pain, shorter hospitalization times, and faster patient recovery than sternotomy procedures, complications are also possible with minimally invasive endoscopic surgery. Portal site metastasis can develop from contamination of portal sites with cells on instruments or cannulas or via leakage of effusion fluid. Although rare, this potential complication should be discussed with owners prior to performing the procedure.

Comparison of laparoscopically assisted and open radical distal gastrectomy with extended lymphadenectomy for gastric cancer management

BACKGROUND

The feasibility and safety of laparoscopically assisted gastrectomy with extended lymphadenectomy for advanced gastric cancer has rarely been studied. This study aimed to investigate the feasibility, safety, and cancer clearance of laparoscopically assisted distal gastrectomy with D2 lymphadenectomy.

METHODS

Of the 44 patients with distal gastric cancer who underwent radical distal gastrectomy from March 2004 to May 2005, 35 were treated with D2/D2(+) lymphadenectomy. These patients were compared with 58 patients who, during the same period, underwent a conventional open radical distal gastrectomy.

RESULTS

The mean total number of retrieved lymph nodes (30.11 +/- 16.97) and the mean tumor margin were comparable with those in the open group. The mean operative time for laparoscopically assisted distal gastrectomy was significantly longer than for open surgery (282.84 +/- 32.81 min vs 223.75 +/- 23.25 min). The patients in the laparoscopic surgery group had less blood loss, shorter times of analgesic injection, and a faster recovery. The rates of complications were comparable between two groups.

CONCLUSIONS

Although laparoscopically assisted radical gastrectomy with D2 lymphadenectomy is more time consuming than open surgery, it is a safe, feasible procedure that achieves cancer clearance similar to open surgery and leads to a quick postoperative recovery.

Does CO2 pneumoperitoneum alter the ultra-structuture of the mesothelium?

BACKGROUND

Pneumoperitoneum may be responsible for ultra-structural alterations in the mesothelium during laparoscopy. To characterize the effect of pneumoperitoneum on the mesothelial cells with CO(2) and compressed air; and to compare to laparotomy and control group (anesthesia only).

MATERIALS AND METHODS

Forty C-57 mice were divided in four groups of 10 animals each: CO(2), air, laparotomy, and control group. The animals were submitted to pneumoperitoneum at 8 mmHg during 30 min (CO(2) or compressed air). Five animals of each group were sacrificed 2 and 24 h after the procedure. Fragments of parietal peritoneum were collected and processed for scanning electron microscopy.

RESULTS

Control group revealed uninterrupted mesothelial cells, without any evidence of cellular limits; close contact between the cells; absence of intercellular clefts and presence of microvilli. In the laparotomy group, similar results to the control group, with decreased microvilli were noted. Air pneumoperitoneum was associated with alterations in the morphology of the mesothelial cells, clear cellular limits, and cells with spherical and fusiforme formats. CO(2) pneumoperitoneum showed mesothelial cells with clear cellular limits, predominantly spherical cellular format, and intercellular clefts that allowed the visualization of the exposed basal membrane. These alterations were more intense after 24 h. There was a statistical significance between CO(2) group (2 and 24 h) compared to the control group and laparotomy for cellular limits, intercellular clefts and microvilli, P < 0.0001.

CONCLUSIONS

Pneumoperitoneum causes damage in the mesothelial ultra-structure, which differs from the laparotomy group. CO(2) pneumoperitoneum is more harmful to the mesothelium than the air.

Pneumoperitoneum does not influence trocar site implantation during tumor manipulation in a solid tumor model

BACKGROUND

The purpose of this study was to assess tumor implantation at abdominal wound sites following manipulation of a solid abdominal tumor.

METHODS

GW-39 human colon cancer cells were injected into the omentum of golden Syrian hamsters. At 2 weeks, an omental tumor was harvested and animals were randomized to bivalve (A), crush (B), strip (C), or excision (D), with or without pneumoperitoneum. Four 5-mm trocars were inserted into the abdomen, and the tumor was reinserted through the midline, swept through four quadrants, and removed. The incision was closed and pneumoperitoneum at 7 mmHg was maintained for 10 min. Tumor implantation at wound sites was documented at 7 weeks.

RESULTS

Implantation at trocar sites was 53 and 49% with and without pneumoperitoneum in the manipulated groups (A, B, C), respectively (p = 0.993). Implantation at trocar sites was reduced in the control group (D) at 9 and 10% with and without pneumoperitoneum, respectively (p < 0.001).

CONCLUSIONS

Tumor implantation at trocar sites is due to spillage of tumor during manipulation and not to pneumoperitoneum.

Laparoscopic port-site metastases in patients with gynecological malignancies

OBJECTIVE

The purpose of this study is to review all reported cases of laparoscopic port-site metastases in patients with gynecological malignancies. Potential etiologies as well as options for prevention are discussed.

METHODS

We searched the Medline database for English-language articles presenting raw data on laparoscopic port-site metastases in patients with gynecological malignancies.

RESULTS

We found 31 articles describing port-site metastases in 58 patients. Forty patients had low malignant potential (seven patients) or invasive ovarian carcinoma (33 patients). The median age of these patients was 50 years (range: 22-79), and 83% had advanced (stage III or IV) disease. Seventy-one percent of the patients (24 of 34) had ascites, and 97% (29 of 30) had carcinomatosis. Seventy-five percent of the laparoscopic procedures in this group were performed for diagnosis. Median time to diagnosis of port-site metastases was 17 days (range: 4-730). Seventy-one percent of port-site recurrences (15 of 21) were isolated to a tissue-manipulating port. Twelve patients had port-site metastases after laparoscopy for cervical cancer. The median age was 44 years (range: 31-74). Eighty percent of cases were squamous cell carcinoma. In 75% of the patients, laparoscopy was performed for therapeutic purposes. The median time to diagnosis of port-site metastases was 5 months (range: 1.5-19). Four patients had port-site metastases after laparoscopy for uterine cancer. The median age was 63 years (range: 56-72). The median time to diagnosis of metastases was 13.5 months (range: 6-21). Half of the recurrences were in the tissue-manipulating port. Port-site metastases after laparoscopy were reported for one patient each with a diagnosis of fallopian tube carcinoma and vaginal carcinoma.

CONCLUSIONS

Laparoscopic port-site metastases are a potential complication of laparoscopy in patients with gynecological malignancies, even in patients with early-stage disease.

Laparoscopy and Malignancy

BACKGROUND

The advantages of pneumoperitoneum-based surgery are well documented. Laparoscopy is the gold standard of treatment in certain benign conditions such as cholelithiasis and gastroesophageal disease. This success has led to the application of laparoscopy in the management algorithm of malignant conditions. There is currently no universally accepted consensus of the role of pneumoperitoneum-based surgery in the treatment of cancer. This is due to the early reports of port site metastasis, initial lack of randomized controlled trials and the concern of performing oncologically adequate operations. The aim of this section is to review the current literature and attempt to obtain a consensus of the role of laparoscopy in the treatment of cancer.

MATERIALS AND METHODS

A literature search was conducted through Pubmed with key words laparoscopy, pneumoperitoneum, carbon dioxide, malignancy, cancer, and port site metastasis. The obtained results were divided into various sections such as non-randomized reports, randomized reports, animal studies, human studies, etc. A comparison was made between laparoscopic and open resections when possible.

RESULTS

There are several published reports of studies in animal models and in humans relating to pneumoperitoneum-based surgery in the setting of malignancy. There are also a few randomized controlled trials that compared open versus laparoscopic surgery for malignancies of various organ systems. In addition, the early reports of alarmingly high rate of port site metastasis have been scaled down to rates comparable to wound recurrences after open resections.

SUMMARY

Laparoscopy has added another dimension to the management of patients with cancer. Advanced training, superior instrumentation, and a better understanding of the pathophysiology of carbon dioxide pneumoperitoneum has led to the successful application of laparoscopy. The improved results are obtained in centers with high volume of patients and with experience in both fields of oncology and minimally invasive surgery. Laparoscopy is now an integral tool in the management algorithm of malignancies of some organ systems and its role will be further expanded in the future.

Effect of carbon dioxide pneumoperitoneum and wound closure technique on port site tumor implantation in a rat model

BACKGROUND

The purpose of this study was to evaluate the effects of carbon dioxide (CO2) pneumoperitoneum and wound closure technique on port site tumor implantation.

METHODS

A standard quantity of rat mammary adenocarcinoma (SMT2A)was allowed to grow in a flank incision in Wistar-Furth rats (n = 90) for 14 days. Thereafter, 1-cm incisions were made in each animal in three quadrants. There were six control animals. The experimental animals were divided into a 60-min CO2 pneumoperitoneum group (n = 42) and a no pneumoperitoneum (n = 42) group. The flank tumor was lacerated transabdominally in the experimental groups. The three wound sites were randomized to closure of (a) skin; (b) skin and fascia; and (c) skin, fascia, and peritoneum. The abdominal wounds were harvested en bloc on postoperative day 7.

RESULTS

Histologic comparison of the port sites in the pneumoperitoneum and no-pneumoperitoneum groups did not demonstrate a statistically significant difference in tumor implantation for any of the closure methods. Evaluation of the closure techniques showed no statistical difference between the pneumoperitoneum group and the no-pneumoperitoneum group in the incidence of port site tumor implantation. Within the no-pneumoperitoneum group, there was a significant increase (p = 0.03) in tumor implantation with skin closure alone vs all three layers. Additionally, when we compared all groups by closure technique, the rate of tumor implantation was found to be significantly higher (p = 0.01) for skin closure alone vs closure of all three layers.

CONCLUSIONS

This study suggests that closure technique may influence the rate of port site tumor implantation. The use of a CO2 pneumoperitoneum did not alter the incidence of port site tumor implantation at 7 days postoperatively.

Minimally Invasive Treatment of Stomach Cancer

The rate of detection of early gastric cancer has increased because of the development of diagnostic techniques, such as endoscopy, biopsy, and endoscopic ultrasonography. Recently, minimally invasive surgical procedures for benign gastric conditions have been advocated, and the laparoscopic approach is noted as a technique that increases the quality of life. However, the development of laparoscopic gastric resections and laparoscopically assisted gastric operations for malignancy still deserve a word of caution. Laparoscopic local resection of the stomach is used to treat mucosal cancer without lymph node metastasis, and laparoscopy-assisted distal gastrectomy is used to treat early gastric cancer with lymph node metastasis in the perigastric portion. According to short-term results reported by a small group of surgeons, laparoscopic approaches for gastric cancer result in a minimally invasive approach, early recovery, and decreased morbidity and mortality. However, the longterm results of these less invasive treatments are not known in advanced gastric cancer. If the results of randomized controlled studies for advanced gastric cancer are confirmed, the use of these techniques will spread worldwide and may become a standard technique for the resection of gastric cancer.

Morphology of the rat peritoneum after carbon dioxide and helium pneumoperitoneum: a scanning electron microscopic study

BACKGROUND

Laparoscopic surgery for patients with cancer has been debated because of the susceptibility that laparoscopic incisions have shown for metastatic tumor growth. Structural damage of the mesothelial layer attributable to the pneumoperitoneum may facilitate intraabdominal tumor cell adhesion and growth. The influence of carbon dioxide (CO(2)) and helium pneumoperitoneum on the morphology of the peritoneum was examined.

METHODS

A total of 50 rats received colon carcinoma (DHB/TRb) cells intraperitoneally and CO(2) (n = 25) or helium (n = 25) pneumoperitoneum at 15 mmHg for 15 min. After different periods (2, 12, 24, 48, and 96 h), the rats were killed, and the peritoneum was examined by scanning electron microscopy. Control animals (n = 5) were without pneumoperitoneum.

RESULTS

The control animals and most of the rats with pneumoperitoneum showed no peritoneal alterations. In four animals of each group, inflammatory alterations of the peritoneum such as bulging and retraction of mesothelial cells were observed at different time points. Tumor cells adherent to the peritoneum were found in a total of six animals. Peritoneal carcinomatosis, tumor nodules, or infiltration of the peritoneum by tumor cells was not observed.

CONCLUSIONS

The study demonstrated that the morphologic integrity of the rat peritoneum is not disturbed when CO(2) or helium is used for insufflation combined with the intraperitoneal injection of carcinoma cells. Pneumoperitoneum therefore probably is not the condition causing peritoneal changes that favor intraperitoneal tumor growth.

Port site metastases

BACKGROUND

Concerns about port site metastases have limited the application of minimally invasive surgery for intra-abdominal malignancies. The purpose of this review article was to summarize the current literature regarding port site metastases.

METHODS

A Medline search identified >100 articles in English published during the last 15 years regarding the history, incidence, etiology, and prevention of port site metastases. These articles were reviewed and are summarized.

RESULTS

The incidence of port site metastases, initially thought to be as high as 21%, is now thought to be closer to the incidence of wound metastases after open surgery. Multiple etiologic factors have been studied including direct wound contamination, surgical technique, effects of carbon dioxide pneumoperitoneum, and changes in host immune response. Various preventive measures have been proposed.

CONCLUSIONS

Port site metastases are a well-documented and devastating complication after laparoscopic resection of intra-abdominal malignancies. Although the etiology is not yet understood, a number of factors are contributory. All efforts should be made to prevent port site metastases.

Laparoscopic colon resection for colon cancer

INTRODUCTION

Laparoscopic colon resection for cancer is as yet an unproven operation. This review article summarizes current data on the topic.

METHODS

A Medline review identified articles published since 1990 summarizing patients with potentially curable colon cancer who underwent a laparoscopic-assisted colon resection. Only articles that were randomized or had a control group with historical or matched open cases were used.

RESULTS

Very few prospective randomized controls exist. Several clinical trials are under way with one completed. Data thus far support some patient benefits with a laparoscopic approach. No differences in morbidity, oncologic data, or survival appear to exist.

CONCLUSIONS

The results of ongoing clinical trials are still needed to further evaluate the role of laparoscopic assisted colon resection in patients with potentially curable colon cancer.

The effects of staging laparoscopy on trocar site and peritoneal recurrence of pancreatic cancer

BACKGROUND

Staging laparoscopy (SL) has been used to assess resectability of patients with pancreatic cancer. It has lead to increased resectability rates and decreased morbidity. However, experimental data suggests that laparoscopy and peritoneal insufflation can promote tumor growth and potential recurrence. Few clinical data exist to allow assessment of whether these theoretical concerns translate into clinical problems. The purpose of this study was to determine if SL increases the incidence of trocar-site and peritoneal recurrence of pancreatic cancer.

METHODS

A retrospective review of all patients evaluated for pancreatic cancer from 1996 to 2001, inclusive, was included in this study. Patients were divided into five groups: nonoperative management (NM), SL followed by resection (SL-R), SL without resection (SL-NR), exploratory laparotomy with resection (EL-R), and exploratory laparotomy without resection (EL-NR). Patient records were assessed for postoperative occurrence of carcinomatosis and/or malignant ascites, trocar- or incisional-site recurrence, use of postoperative chemotherapy or radiation therapy, and survival.

RESULTS

A total of 235 patients were included. Peritoneal progression of disease: NM 15.9%, SL 24.2%, EL 31.6% ( p = 0.03). Trocar/incisional recurrence: SL 3.0%, EL 3.9% ( p = NS). Use of chemotherapy/radiotherapy: NM 29.4%, SL-R 76.5%, SL-NR 62.5%, EL-R 69.6%, EL-NR 41.5%. Median survival (months): NM 3; SL-R 15, EL-R 10 ( p = NS); SL-NR 6, EL-NR 5 ( p = NS).

CONCLUSION

SL does not increase the occurrence of trocar-site disease or peritoneal disease progression of pancreatic cancer. Patients who are found not to be resectable by SL are more likely to receive postoperative treatment. However, this does not appear to affect survival greatly. Nevertheless, avoidance of nontherapeutic laparotomy is worthwhile in these patients.

Laparoscopic port-site metastases: etiology and prevention

OBJECTIVE

The purpose of this article is to summarize current hypotheses for the possible sources of laparoscopic port-site metastasis, to review the results of experimental models that support such hypotheses, and to discuss the potential options for preventing these metastases.

METHODS

We performed a Medline search to identify in vitro and in vivo studies and clinical trials that analyzed port-site metastases associated with laparoscopic surgery. We report the incidence of port-site metastases and causative factors associated with this condition.

RESULTS

The estimated incidence of port-site metastases in all patients undergoing laparoscopic surgery for malignant disease is approximately 1-2%. Multiple factors are associated with this complication. Among the most common proposed etiologies are the wound implantations caused by the surgical technique and instrumentation; the leakage of insufflation gas through the ports, known as the "chimney effect"; and the impact of pneumoperitoneum on local immune reactions. Several preventive measures, have been suggested, including careful patient selection, lavage of the peritoneal cavity as well as of the port wounds with cytotoxic agents, and modifications of surgical technique.

CONCLUSIONS

Only through the results of well-conducted large multi-institutional prospective randomized trials will we learn not only the true incidence of port-site metastases, but also the potential factors that lead to the occurrence of this complication.

Port site metastases in urological laparoscopic surgery

PURPOSE

Laparoscopic surgery is rapidly gaining widespread acceptance among urologists, including extensive application in malignant conditions. However, untoward occurrences of port site metastases have not eluded to urological applications. This up-to-date review on port site metastases in urology delineates possible contributing factors and describes techniques to prevent it.

MATERIALS AND METHODS

We comprehensively reviewed published experimental and clinical studies with special emphasis on the incidence, pathophysiology and prevention of port site metastases.

RESULTS

Nine cases of port site metastases after urological laparoscopy have been described in clinical and experimental studies. Etiological factors include natural malignant disease behavior, host immune status, local wound factors, laparoscopy related factors such as aerosolization of tumor cells (the use of gas, type of gas, insufflation and desufflation, and pneumoperitoneum) and sufficient technical experience of the surgeons and operating team (adequate laparoscopic equipment, skill, minimal handling of the tumor, surgical manipulation and wound contamination during instruments change, organ morcellation and specimen removal).

CONCLUSIONS

Port site metastases is a multifactorial phenomenon with an as yet undetermined incidence. The problem is influenced to some extent by surgeon and operating team experience and, therefore, it could be partially prevented. The suggested preventive steps are avoiding laparoscopic surgery when there are ascites, trocar fixation to prevent dislodgment, avoiding gas leakage along and around the trocar, sufficient technical readiness of the operating team (adequate laparoscopic equipment and technique, minimal handling and avoiding tumor boundary violation of the tumor), using a bag for specimen removal, placing drainage when needed before desufflation, povidone-iodine irrigation of instruments, trocars and port site wounds, and suturing 10 mm. and larger trocar wounds.

Laparoscopic total mesorectal excision: a consecutive series of 100 patients

OBJECTIVE

To analyze total mesorectal excision (TME) for rectal cancer by the laparoscopic approach during a prospective nonrandomized trial.

SUMMARY BACKGROUND DATA

Improved local control and survival rates in the treatment of rectal cancer have been reported after TME.

METHODS

The authors conducted a prospective consecutive series of 100 laparoscopic TMEs for low and mid-rectal tumors. All patients had a sphincter-saving procedure. Case selection, surgical technique, and clinical and oncologic results were reviewed.

RESULTS

The distal limit of rectal neoplasm was on average 6.1 (range 3-12) cm from the anal verge. The mean operative time was 250 (range 110-540) minutes. The conversion rate was 12%. Excluding the patient who stayed 104 days after a severe fistula and reoperation, the mean postoperative stay was 12.05 (range 5-53) days. The 30-day mortality was 2% and the overall postoperative morbidity was 36%, including 17 anastomotic leaks. Of 87 malignant cases, 70 (80.4%) had a minimum follow-up of 12 months, with a median follow-up of 45.7 (range 12-72) months. During this period 18.5% (13/70) died of cancer and 8.5% (6/70) are alive with metastatic disease. The port-site metastasis rate was 1.4% (1/70): a rectal cancer stage IV presented with a parietal recurrence at 17 months after surgery. The locoregional pelvic recurrence rate was 4.2% (3/70): three rectal cancers stage III at 19, 13, and 7 postoperative months.

CONCLUSIONS

Laparoscopic TME is a feasible but technically demanding procedure (12% conversion rate). This series confirms the safety of the procedure, while oncologic results are at present comparable to the open published series with the limitation of a short follow-up period. Further studies and possibly randomized series will be necessary to evaluate long-term clinical outcome in cancer patients.

Abdominal wall recurrences after colorectal resection for cancer: results of the Italian registry of laparoscopic colorectal surgery

PURPOSE

The purpose of the present study was to evaluate prospectively the abdominal wall recurrence rate after laparoscopic resection for colorectal cancer, to analyze the impact of the learning curve on abdominal wall recurrence, and to assess the outcome of those patients.

METHODS

The Italian Registry of Laparoscopic Colorectal Surgery database was analyzed to obtain data on cancer patients with abdominal wall recurrence, concomitant local or distant metastases, and interval between initial surgery and diagnosis of trocar site or minilaparotomy recurrences. The records of the initial procedures and the technique of specimen removal were reviewed.

RESULTS

From January 1992 to July 2000, 2,583 patients (1,753 cases of carcinomas and 830 cases of benign diseases) were recorded. The malignant lesions were located on the right colon in 19 percent, the left colon in 48.8 percent, and rectum in 32.2 percent. Sixteen patients with histologic evidence of colorectal adenocarcinoma recurrences at the abdominal wall were observed (0.9 percent). Ten patients presented an advanced stage (III for 7 patients and IV for 3 patients). Eleven cases occurred during the learning curve period (the first 50 consecutive cases). The median survival time after abdominal wall recurrence diagnosis was 16 (range, 12-60) months. By July 2000 only two patients were alive.

CONCLUSIONS

The results of the Italian prospective Registry of Laparoscopic Colorectal Surgery confirm that the incidence of abdominal wall recurrences is similar to that reported in open studies (<1 percent). Most abdominal wall recurrences occurred in the learning curve period, suggesting that surgical experience may play a role in the development of this outcome. The prognosis of these patients is very poor.

Port site metastasis after diagnostic laparoscopy for upper gastrointestinal tract malignancies: an uncommon entity

BACKGROUND

The role of laparoscopy for diagnosing, staging, and treating intra-abdominal malignancies is increasing. This study was designed to examine the incidence of port site metastasis and open incision site metastasis for upper gastrointestinal tract (GI) malignancies.

METHODS

From a prospective database maintained by the Department of Surgery, patients undergoing laparoscopy for upper GI malignancies were identified. Clinical outcomes and recurrences were noted.

RESULTS

Between January 1993 and January 2001, 1965 laparoscopic procedures were identified. After those patients lost to follow-up were excluded, 1650 procedures were performed in 1548 patients. Port site implantation for all laparoscopies occurred in 13 (.79%) of 1650, with a median time to recurrence of 8.2 months. After laparotomy, open incision site recurrence occurred in 9 (.86%) of 1040 (not significant). Among the patients resected, there were 5 (.60%) of 830 port site recurrences and 7 (.84%) of 830 open incision site recurrences. At the time of diagnosis of recurrence, all of the patients with port site and five of seven with open site implantation had distant or local disease, or both, as well.

CONCLUSIONS

Port site implantation after diagnostic laparoscopy for upper GI malignancy is uncommon, does not seem to be different from open incision site recurrence, and occurs in the setting of advanced disease. Therefore, the risk of port site recurrence cannot be used as an argument against laparoscopy in upper GI malignancy.

Tumour implantation following laparoscopy using different insufflation gases

BACKGROUND

Because of the possibility of intraperitoneal seeding and port-site recurrences following laparoscopic surgery, the role of laparoscopy in cancer surgery remains controversial. Previous experimental studies have suggested that chemical, metabolic and immunological changes following carbon dioxide (CO2) insufflation may be responsible for this phenomenon. Earlier experimental studies done by the University of Adelaide Department of Surgery have also shown that helium insufflation is associated with none of the adverse changes brought about by CO2 insufflation. Helium insufflation is also associated with lower rates of intra-abdominal tumour spread. The aim of this study was to determine whether these identified benefits apply to inert gases in general.

METHODS

Twenty-four Dark Agouti rats were randomized to undergo laparoscopy with 40 min insufflation using one of the following four gases (six rats in each group); CO2, helium, argon and nitrogen. A tumour cell suspension was injected into the abdominal cavity at the beginning of laparoscopy. The rats were killed 7 days after surgery, and the peritoneal cavity and port sites were examined for the presence of tumour.

RESULTS

Rats undergoing helium insufflation, had the least number of port-site recurrences and the least amount of intraperitoneal tumour spread. Argon and nitrogen pneumoperitoneum were associated with a large number of port-site recurrences and widespread tumour seeding. The effect of CO2 insufflation was intermediate.

CONCLUSION

The choice of insufflation gas influences the incidence of port-site metastases and the degree of intraperitoneal tumour spread following laparoscopic cancer surgery. The reduced port-site recurrences and intraperitoneal spread that followed helium pneumoperitoneum is likely to be a unique property of this gas rather than a property of inert gases in general.

Hand-assisted laparoscopic surgery for cancer

Minimally invasive surgical approaches were designed to enhance quality of care and improve patient outcome by minimizing postoperative pain, shortening hospital stay, reducing costs, and facilitating early return to work and presurgical lifestyle. The hand-assisted laparoscopic approach for resection of cancer is still in its formative stage, and this review places it in proper perspective within the context of minimally invasive surgery currently being performed for both benign and malignant disease. The review also outlines the potential advantages and disadvantages, techniques, and site-specific procedures of hand-assisted laparoscopic surgery for cancer.

[Laparoscopy and gynecologic cancer: is it still necessary to debate or only convince the incredulous?]

Many papers suggested that laparoscopic treatment of cancer could be achieved and taught safely. Although cases reports about trocar site metastasis and national survey about inadequate management of early ovarian cancer suggested that laparoscopic management of cancer may be dangerous. The current literature may be summarized as follows. An inadequate surgical management performed by laparoscopy as well as by laparotomy may worsen the prognosis of an early ovarian cancer. If the abdominal wall is protected with a bag and the tumour is not morcellated, the incidence of trocar site site metastasis is about 1%. Animal studies demonstrated that the laparoscopic management of cancer has both advantages and disadvantages. Preliminary results from prospective randomised trials in the treatment of colon cancer suggested that the survival rate is similar after laparoscopy and after laparotomy. The risk of dissemination appears high when a large number of malignant cells are present in patients operated using an increased abdominal pressure and a CO2 pneumoperitoneum. These data suggest that laparoscopic treatment of gynaecologic cancer is not dangerous if an adequate surgical technique is used. However morcellation of suspicious solid tumours, treatment of adnexal tumours with external vegetations but without peritoneal dissemination and of bulky lymph nodes should be considered as contra-indications to CO2 laparoscopy, puncture of an ovarian tumour with intracystic vegetations is a high risk situation which should be avoided whenever possible.

CO2 pneumoperitoneum does not enhance tumor growth and metastasis: study of a rat cecal wall inoculation model

INTRODUCTION

Although many studies have evaluated the effects of carbon dioxide pneumoperitoneum on port site recurrence, little is known about its outcome on tumor growth and metastasis. The effect of pneumoperitoneum with carbon dioxide on cecal tumor growth and metastasis was compared with laparotomy using a rat colon cancer cell line.

METHODS

Time Course Study: Fifty WF/BN F1 hybrid rats were inoculated with 2,000,000 WB2054M5 tumor cells into the cecal wall and explored two to ten weeks after injection. Main Study: 152 rats were randomly assigned either to 6-mmHg CO2 pneumoperitoneum (30 minutes) or 4-cm laparotomy (30 minutes) two weeks after tumor inoculation and were explored four weeks after treatment.

RESULTS

Time Course Study: Thirty-seven (95 percent) of the surviving rats developed a cecal wall tumor, and there was progressive tumor growth and metastasis over the ten-week period. At six weeks, metastasis occurred to the liver in 25 percent, to the lung in 38 percent, and to the lymph node in 63 percent, and peritoneal seeding occurred in 38 percent; this time period was chosen for the main study. Main Study: At the time of treatment (2 weeks), 124 rats were eligible for randomization. One hundred two rats survived the six-week period (50 pneumoperitoneum, 52 laparotomy) and were killed. There were no differences between the CO2 pneumoperitoneum and laparotomy groups regarding cecal tumor growth (1.043 vs. 0.894 g) and metastases to the liver (32 vs. 37 percent), lung (34 vs. 17 percent), lymph node (84 vs. 77 percent), and wound or port (20 vs. 23 percent).

CONCLUSIONS

A cecal wall inoculation model mimics the natural cascade of colon cancer growth and metastasis. CO2 pneumoperitoneum did not affect the tumor growth and metastasis to the liver and other organs when compared with laparotomy in this model.

Validation of a new experimental model of colon cancer

BACKGROUND

Most of the published animal studies that have evaluated tumor growth and port site metastases in laparoscopy have utilized a cell suspension model and thus cannot be compared to the clinical situation. Although solid tumor models have been developed, there has been no experimental model that establishes an orthotopic tumor in the rectum, reflecting the clinical situation of a solid colonic cancer.

METHODS

Tumor cells (colon adenocarcinoma DHD/K1/TRb) were administered intraperitoneally in rats, which were used as solid tumor donors. A 20-mg piece of solid tumor from the donor was placed in a submucosal blister created in the rectum wall of the study rats. The approach to the submucosal blister was made through the mucosa after contralateral enterotomy. In order to validate the model, this intervention was performed in 10 cases (group A). After 10 days of intervention, the rats were submitted to resection of the rectum and histological examination of the specimen. In another 10 rats (group B), manipulation of the tumor was performed after 10 days to cause tumor cell spillage. The likelihood of tumor dissemination was investigated in this group 20 days after this intervention.

RESULTS

Group A developed solid tumors in seven of 10 cases (70%). All of the tumors were localized between the muscular and the mucosal layer, with preservation of the serosa and without affecting the enterotomy. In all of the rats in group B, macroscopic tumor was observed in the upper rectum (100%) 10 days after its induction. Twenty days after tumor manipulation, nine rats had local tumor dissemination; two of them also had general tumor dissemination in the abdominal cavity.

CONCLUSIONS

We established a novel solid colonic tumor model in rats for the investigation of intraoperative tumor cell spillage during resection of the colon and the development of port site metastases.

Trocar site recurrence in laparoscopic surgery for colorectal cancer

BACKGROUND

Laparoscopic colorectal surgery has been associated with less postoperative pain, an early return of bowel function, a shorter period of hospitalization and disability, and better cosmetic results. However, the application of laparoscopic techniques to the curative resection of colorectal cancer is still controversial, owing to reports of cancer recurrence at the port site wounds. The accumulation of numerous such reports in a relatively short period raised concern that there might be an extraordinary high rate of port site metastases after laparoscopic colorectal surgery. This concern has led to intense clinical and basic research aimed at determining the incidence and causes of wound recurrence and developing preventative measures to address this problem. Despite these efforts, it is still not clear whether port site metastasis is really an inherent drawback to laparoscopic cancer surgery.

METHODS

In this review of the literature on port site metastasis, we gathered data from clinical series of laparoscopic surgery for colorectal cancer. We eliminated series of <50 patients, since they may be flawed by the learning curve required for this technically demanding procedure.

RESULTS

The rate of port site recurrences in the 1737 patients who participated in these series was 1%. Although the methods and criteria for patient selection in these studies varied, this figure appears to be comparable to the incidence reported for other malignancies and for laparotomies performed to treat colorectal cancer.

CONCLUSION

This review suggests that wound recurrence may actually be the result of an unfortunate learning curve, rather than an inherent concern. However, we must await the final results of large randomized studies before drawing any definitive conclusions.