Minimally invasive surgery has revolutionized the way surgeons practice colorectal surgery. It has resulted in decreased lengths of stay and a marked decrease in wound infections and has shown some evidence of an overall lower complication rate versus open surgery [1]. This chapter will outline the history of minimally invasive colorectal surgery, examine evidence detailing its safety compared with open surgery, discuss the learning curve required to achieve proficiency, and outline the extent of its current use.

Laparoscopy is not a new invention. Its first use was described long before we think of contemporary surgery. In fact, Aulus Cornelius Celsus (25 B.C.–50 A.D.) was the first to describe the use of percutaneous devices (now called trocars) to “drain evil humors” [2]. The term “trocar” was coined in 1706 and was thought to be derived from the term “trochartortroise-quarts,” a three-faced instrument consisting of a perforator enclosed in a metal cannula. The first use of a device used to peer inside the abdominal cavity was in 1901 by George Kelling, a German surgeon, who used a cystoscope to examine the abdominal viscera of a dog after insufflating the peritoneal cavity with air. In 1910, Jacobeus performed the first laparoscopic drainage of ascites in humans in Sweden [3]. In 1911, Bertram Bernheim published his series from Johns Hopkins entitled “Organoscopy: Cystoscopy of the Abdominal Cavity” [4]. As technology improved, so did the capability of laparoscopic procedures. In 1929, Heinz Kalk, a German gastroenterologist, developed a 135-degree lens system and a dual-trocar approach. Ten years later, he published his experience of 2,000 liver biopsies performed using local anesthesia without a single mortality [5].

Early laparoscopy was not without its problems. The combination of a high rate of trocar injury to bowel, lack of an alternative to unipolar cautery (which caused a number of additional bowel and other organ injuries), and lack of a regulator to prevent high insufflation pressures meant that many surgeons deemed laparoscopy as too high risk. In addition, visualization was extremely poor because there was no good method to illuminate the abdominal cavity, and the eyepiece limited the field of vision to a narrow area. It was not until 1952 when Fourestier, Gladu, and Valmiere developed a new lighting system that revolutionized endoscopy. They utilized a quartz rod to transmit an intense light beam distally along a telescope and permitted the light intensity to be concentrated enough to photograph images [6]. In 1960, German gynecologist Kurt Semm invented an automatic insufflator that solved the insufflation pressure problem [7]. Finally, in the early 1980s, the first solid-state camera was introduced that allowed video laparoscopy. Prior to this, an eyepiece was required that only allowed a single observer to visualize the abdominal cavity.

Despite these advances, it took a long time for more complex laparoscopic surgeries to be considered. Mühe performed the first laparoscopic cholecystectomy in the mid-1980s, several years after the development of video laparoscopy [8, 9]. The single most important invention that allowed laparoscopic colorectal surgeries to be performed was the laparoscopic stapler. This allowed the first colorectal procedures to be performed.

The first laparoscopic colonic resection was a right hemicolectomy performed by Moises Jacobs in Miami, Florida, in June of 1990. Dennis Fowler performed the first laparoscopic sigmoid resection in October of 1990. Joseph Uddo performed a laparoscopic colostomy closure on November 14, 1990 (anastomosis was constructed with a circular stapling device). Patrick Leahy resected a proximal rectal cancer with low anterior anastomosis. And on July 26, 1991, Joseph Uddo performed an entirely laparoscopic right hemicolectomy when the ileocolic anastomosis was constructed intracorporeally. From this point on, many surgeons throughout the world started to perform laparoscopic surgery [10, 11].

As is the case with any new technology or procedure, there were skeptics. An important question was whether the laparoscopic approach was equivalent oncologically to the traditional open method. Some early reports of trocar site recurrences following laparoscopic resections raised concern among many [12]. In addition, early results of studies that included laparoscopic treatment of rectal cancer showed a trend towards higher rates of positive circumferential margins and a high conversion rate of 34 % [13]. However, long-term follow-up has demonstrated this not to be true.

Several randomized trials have now shown no difference in survival and local recurrence rates when comparing laparoscopic to open approaches. In fact, laparoscopic approaches even have some advantages over open surgery. The COST trial [14], COLOR trial [15], and CLASICC trial [13, 16] have shown the procedure to be safe with similar outcomes to open surgery. Potential benefits were discovered in a Cochrane Review, where the laparoscopic approach resulted in decreased blood loss, a quicker return to diet, less pain (measured by narcotic use), and lower rate of wound complications as compared to open surgery. These differences were obtained while showing no difference in margins or lymph nodes and similar mortality/leak rates [17]. These results were further confirmed by a study that examined national trends among 402 hospitals. Laparoscopic approach to colectomy resulted in longer operative time (195 vs. 80 min) but a shorter mean hospital stay (7.0 vs. 8.1 days), fewer transfusions (odds ratio 0.68), fewer in-hospital complications, and less readmissions within 30 days (odds ratio 0.89) [1]. The use of enhanced recovery protocols has further decreased the length of stay and the rate of complications, though how much is due to a laparoscopic approach and how much is due to the enhanced recovery are difficult to separate [18].

Laparoscopic colon surgery is in every sense of the word complex. It requires surgery in multiple quadrants, large vessel ligation, bowel division, and re-anastomosis. Performing these tasks requires a significant amount of skill in a laparoscopic arena, where tactile sensation and multiple specialized retractors are not available. In addition, laparoscopic colon resection requires correct identification of planes that are not typically used in an open approach (for medial to lateral dissection). For these reasons, and the fact that the procedures often take longer than open surgery, laparoscopic colorectal surgery is not for the faint hearted. After performing a laparoscopic total proctocolectomy, which combines the difficulties of colon resection in all quadrants, Theodore Saclarides once said: “The patient looks better than the surgeon the next day.” Anyone who has performed laparoscopy in an obese patient can understand this statement.

As part of some of the aforementioned randomized trials looking at outcomes for laparoscopic surgery, participants had to demonstrate successful performance of 20 procedures, as this was initially considered to be the learning curve [14]. It was later determined that this was an underestimate. A subsequent study using cumulative sum analysis adjusted for case mix demonstrated that 55 procedures were necessary for right colectomy and 62 procedures for left colectomy to overcome the learning curve [19]. This presents a problem in that the average general surgeon performs ten colon resections per year. At this rate, it would take 5–6 years to overcome the learning curve. Specialized training programs in colorectal surgery allow faster achievement of this goal and have led some to recommend that a specialist only undertakes laparoscopic colon surgery.

Advances in technology have also aided progress. High-definition video laparoscopes improve visualization over the first-generation scopes. Energy devices such as the Harmonic® ACE (Ethicon Endo-Surgery, USA), LigaSure™ (Covidien, USA), and ENSEAL® (Ethicon) give the surgeon greater flexibility to transect vessels varying from 5 to 7 mm in size [20]. Finally, reticulating staplers allow transection of bowel deeper within the pelvis.