Findings During Laparoscopic Colectomy for Cancer: Techniques and Strategies

Fig. 25.1

Preoperative tattooing

At the onset of a laparoscopic procedure, an initial diagnostic laparoscopy should be performed. This entails a general inspection of the peritoneal cavity, liver, and pelvis to look for identifying characteristics of an underlying colonic tumor such as an obvious mass, adherence of omentum to the colon, puckering of the serosa, serosal involvement by the tumor, and visualization of the tattoo markings. If none of the characteristics of a colonic tumor are present and tattooing is not visualized, one needs to consider why the tattoos are not visualized. Is the surgeon looking in the wrong location? Just because a colonoscopy report states a tumor is in the sigmoid, it does not mean that it could not be in the descending, splenic flexure, transverse colon, and at times even more proximal. Flipping the omentum up over the transverse colon should be undertaken as sometimes this maneuver will allow visualization of the tattoos/markings. Lastly, mobilizing the flexure(s) will sometimes allow visualization if tattoos are on the mesenteric surface or blocked by folded or adhesed areas. Another approach is to place a hand port through the expected extraction site to restore tactile sensation and help to identify the tumor and its associated segment.

If all of the above maneuvers are unsuccessful, intraoperative colonoscopy should be performed. For most laparoscopic colorectal procedures, patients should be initially positioned in lithotomy, allowing access to the anus for such potential needs as intraoperative colonoscopy. If this has not already been done, repositioning will be required. Ideally, intraoperative colonoscopy should be performed using CO₂ endoscopy equipment [2]. If unavailable, clamping the terminal ileum will prevent insufflation of the small bowel with room air, which will limit working space and make completion of the surgery more difficult. Once the tumor is identified, placing a tattoo intraoperatively, placing a suture at the site of the tumor, and marking with endoclips are all viable options to preserve identification of the tumor once the colonoscopy has been completed. With all of the tools available both preoperatively and intraoperatively, a “blind colectomy” – without the ability to identify the correct segment prior to excision – should never be performed.

Invasion of Other Organs

Despite preoperative, routine, and high-quality CT scans of the chest, abdomen, and pelvis, more advanced disease does sometimes present intraoperatively. Thus on initial diagnostic laparoscopy, assessment for adherence to or involvement of the tumor to other structures should be undertaken. Structures that a primary colon cancer may be adherent to or invading into would include the abdominal wall, omentum, small bowel, duodenum, stomach, retroperitoneum, bladder, and female reproductive organs including the fallopian tubes, ovaries, uterus, and/or vagina. Other structures may be less frequently involved. Regardless, intraoperative assessment as to the resectability of these structures en bloc with the primary tumor needs to be undertaken. In addition, a decision needs to be made as to whether the procedure should be continued as a laparoscopic approach or converted to an open procedure [3]. Involvement of other specialists, if available, may also be required depending on the expertise of the operating surgeon and the organ(s) involved.

One of “the out of the OR” considerations is the potential lack of informed consent for the additional surgery that may be necessary. Speaking to family members may be of some benefit; however, from a medicolegal standpoint, unless a family member has healthcare power of attorney on behalf of the patient, consent may not be binding or legal. Regardless, doing what is in the patient’s best interest should take precedence and should guide decisions.

The best decision may sometimes be to abort the procedure. However, this is advisable only if an initial diagnostic laparoscopy has been performed. If the procedure has advanced (mobilization, vascular division, etc.) in an effort to recognize any secondary involvement of structures, aborting the procedure is not an option.

If the decision is made to proceed with en bloc resection , the operative team should take a “time-out” to discuss the new operation and the steps required and the need for other teams or services, if required. This will then allow the OR staff, the operative team(s), and potential additional services to be called and prepared.

Synchronous Masses/Tumors

Synchronous tumors or cancers are relatively rare, occurring in less than 1–2% of patients with colon cancer, and are usually intraoperatively identified rather than preoperatively during colonoscopy. Although there is a small “miss rate” on colonoscopy, more typically a synchronous tumor would be proximal to a partially or obstructing tumor that was not traversed at the time of colonoscopy, thereby leaving a segment(s) of the colon that was not endoscopically evaluated. In cases where a complete colonoscopy cannot be performed, a preoperative WSCE is recommended. Not only does WSCE confirm the location of the primary tumor, it can also assess areas that were not endoscopically evaluated. In cases where a second tumor is noted preoperatively, an extended resection or, less commonly, two segmental resections should be performed [4, 5].

If the synchronous tumor is noted intraoperatively, similar options are available to the surgeon and patient. Synchronous tumors should raise the suspicion of hereditary nonpolyposis colorectal cancer (HNPCC) in the appropriately aged patient. Depending on the location of the first and second tumors, the options remain as above: extended resection such as an extended right colectomy, subtotal colectomy, or total colectomy with ileorectal anastomosis . Even in cases of total abdominal colectomy with ileorectal anastomosis, functional outcomes are good with an average of 24-hour bowel function of two to four bowel movements per day.

Meckel’s Diverticulum

Meckel’s diverticulum occurs in 2% of the population as per the “rule of 2s”: a location of 2 feet from the ileocecal valve and ectopic gastric tissue within the diverticulum predisposing to GI bleeding in 2% of cases. Incidentally finding a Meckel’s diverticulum is rarely an indication for surgical excision unless bleeding, perforation, diverticulitis, and obstructions have occurred prior to the incidental identification [6]. However, if a decision is made to excise a Meckel’s diverticulum, it is generally safe and well tolerated.

Peritoneal Carcinomatosis

Patients with peritoneal carcinomatosis (PC) typically have other sites of metastasis. However, PC may be the only site in up to 25%, and in 10% it is diagnosed at the time of surgery [7]. The presence of PC implies a poorer prognosis to the patient. Traditionally, management of PC has included a combination of systemic therapy and cytoreductive surgery (CRS) followed by intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) with mitomycin-C or oxaliplatin (Fig. 25.2). Recently, a French randomized phase III multicenter trial has questioned the addition of HIPEC in these patients showing no difference in survival and an increased incidence of severe complications when compared to CRS alone [8]. Nevertheless, several studies have shown that CRS/HIPEC confers increased median 5-year survival of approximately 30% after R0/R1 resection, depending on the extent of disease and the completeness of CRS [7, 9].