Retrospective review, 372 patients
Local implantation 3.6 % (3 years), distant implantation 1.1 % (3 years)
Survival similar to those reported in OC (3 years)
4 % – stage I
17 % – stage II
31 % – stage III
70 % – stage IV
Prospective comparative trial, 114 patients
Similar between OC and LC 25 % in OC, 28 % in LC (>2 years)
Similar between OC and LC 46 % in OC and LC (>2 years)
Randomized trial, 219 patients
Reduced in LC (95 %CI 0.19–0.82)
Improved in LC (95 % CI 0.16–0.91)
In 2004, the results of the Clinical Outcomes of Surgical Therapy (COST) trial were published in The New England Journal of Medicine. Eight hundred and seventy-two patients in 48 institutions were randomly assigned to open and laparoscopic approach for cancer. 3 years later, there were no difference in tumor recurrence (16 % LC vs. 18 % OC), wound recurrence (<1 % in both LC and OC), or overall survival (86 % LC vs. 85 % OC). The rates of intraoperative and overall complications were similar between the laparoscopic and open group, but perioperative recovery was faster in the laparoscopic surgery group. Another large randomized trial, the Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC), was conducted in the UK. The results of this study were published in 2007. Seven hundred and ninety-four patients in 27 UK medical centers were randomly assigned to laparoscopic (526) and open (268) approach for cancer, in a 2:1 fashion. 3 years later, there was no difference in OS (68.4 % LC vs. 66.7 % OC), DFS (66.3 % LC vs. 67.7 % OC), local recurrence, distant recurrence, or port site/wound recurrence. This trial again confirmed that in terms of recurrence and long-term survival, a laparoscopic approach for colon carcinoma is at least as good as the open approach. In addition, a subset of patients was used to demonstrate that OS, DFS, and local recurrence after laparoscopic rectal resection for rectal cancer were comparable with those of the open approach. The third largest randomized trial, the Colon cancer Laparoscopic or Open Resection (COLOR) trial in Europe, showed similar results, and several meta-analyses have been published from these data, confirming the results. Based on the outcomes of the COST study and other trials, the American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal Surgeons (SAGES) released the following statement: “Laparoscopic colectomy for curable cancer results in equivalent cancer-related survival to open colectomy when performed by experienced surgeons…” [9–11].
Technical difficulty also contributed to the slow adoption of the laparoscopic approach to colorectal cancer. Unlike other laparoscopic procedures such as Nissen fundoplication or cholecystectomy, laparoscopic colorectal resection requires multiple steps, including significant dissection in multiple abdominal quadrants, division of large vessels, removal of a specimen, and reanastomosis. There is a significant learning curve associated with laparoscopic colorectal surgery. It was recommended that a surgeon should have at least 20 laparoscopic colorectal resections to be considered sufficient and probably much more to be considered experienced. Fortunately, developments in video imaging, energy delivery, and stapling technology in the past decades have made it easier for more surgeons to adopt the laparoscopic technique. In addition, some have modified the technique. Surgeons have utilized the insertion of a handport into a small 7–9 cm incision to perform hand-assisted laparoscopic colorectal surgery. Proponents claim that this technique allows tactile and depth sensation and therefore shortens the learning curve. However, to date, there is no convincing evidence supporting clinical or training benefits of this technique over the standard laparoscopic approach.
While initial concerns about poor oncological outcomes associated with laparoscopic colon resection have been put to rest by the mountain of evidence presented, substantial data also demonstrated significant benefits associated with laparoscopic approach. Most of these studies have revealed that laparoscopic approach is linked with decreased hospital stay, less pain, less bleeding, earlier recovery of gastrointestinal function, shorter recovery, and a reduction in wound and other complication rates compared to the open approach [8, 9, 12–14]. Some meta-analyses also showed reduction in perioperative mortality .
A final concern with laparoscopic colectomy is that it may end up being much more expensive than open colectomy. This is particularly noted when length of hospital stay is not reduced or minimally reduced. Many single-center reports that have been published showing improvements or worsening of hospital costs. Most recently, some reports have suggested that in a multicenter approach the procedure can be completed with modest increase in costs of approximately $400 [14, 16–20].
Compared to segmental laparoscopic colon resection, laparoscopic rectal resection is technically more challenging. In the pelvis, manipulation of the bowel and its mesentery are limited by the narrow, long pelvis, particularly in males, tall patients, and in the obese. While avoiding injury to important structures such as the ureters, pelvic autonomic nerves, and the presacral veins, one must perform an oncologically sound total mesorectal excision. Despite these limitations, laparoscopic surgery can potentially enhance pelvic dissection in experienced hands by offering a view with higher magnification. In our opinion, using laparoscopic visualization, the correct anatomical planes can be identified and followed at least as well as in open surgery. Although this could potentially result in improved oncological outcomes and reduction in local recurrence rates, this is unlikely to ever be shown in randomized trials because of variability between patients, surgeons, and techniques, and the fact that the most difficult patients are likely to be performed open because of complicating factors such as prior surgery, obesity, and male gender.
For laparoscopic rectal cancer surgery, there are fewer studies to evaluate the oncological outcomes. However, several series have shown prominent results with laparoscopic approach. Morino et al. reported a prospective series of 100 consecutive laparoscopic TME for middle and low position rectal tumors. The conversion rate was 12 %, anastomotic leak rate was 17 %, and overall postoperative morbidity was 36 %. With a median follow-up of 46 months, the port site metastasis rate was 1.4 % and the overall local recurrence rate was 4.2 %. Five-year survival rates for stage I, II, and III disease were 92 %, 79 %, and 67 %, respectively. This series reveals that the oncological outcomes are equivalent to open published series .
Dulucq et al. reported their 12-year experience of 218 patients with a mean follow-up of 57 months. Seventy six patients underwent laparoscopic anterior resection and 142 patients underwent laparoscopic TME. Their conversion rate was 12 % and anastomotic leak rate was 10.5 %, and no port site metastases occurred. The local recurrence rate was 6.8 %. Overall survival rate was 67 % at 5 years and 53 % at 10 years. The short-term complication rate and the long-term oncological outcome in this series are comparable with their prior open reports. Although a case series, this study also forcefully reveals that laparoscopic anterior resection and TME with anal sphincter preservation of rectal cancer can be safe and effectively performed by experts .
Kim et al. conducted a series of 312 patients who underwent laparoscopic rectal cancer resection performed by a single surgeon. The conversion rate was 2.6 %, anastomotic leak rate was 6.4 %, and overall morbidity rate was 21 %. Sphincter-preserving surgery was performed in 86 %. The circumferential resection margin positivity rate was 4.2 %. Even though only six patients received preoperative radiotherapy, the recurrence rate was 2.9 % at a mean follow-up of 30 months. No port site recurrence was observed. This report demonstrated that laparoscopic rectal cancer resection can achieve remarkable short- and long-term outcomes in highly skilled surgeon .
A meta-analysis carried by Heriot et al. was recently published. The data of all the studies between 1993 and 2004 which compared open and laparoscopic surgery for rectal cancer were pooled and analyzed. Overall, 2,071 patients in 20 studies matched the selection criteria. 990 (44 %) patients underwent laparoscopic surgery and 1,162 (56 %) patients underwent open surgery for rectal cancer. This study showed that there was equivalent in oncologic clearance between laparoscopic and open surgery. However, there were some short-term benefits linked with laparoscopic surgery. It was found that time to first bowel movement, feeding solids, and lengths of hospital stay remarkably reduced after laparoscopic surgery. In abdominoperineal resections patients, wound infection and requirement for postoperative analgesia were also prominently reduced in the laparoscopic group. This study demonstrated that laparoscopic rectal cancer surgery results in a resected specimen that is oncologically equivalent to open surgery and a shorter postoperative recovery .
The largest comparative randomized trial thus far accruing patients with rectal cancer is the CLASSIC trial (shown in Table 11.2). Unlike the COST study, rectal cancers were included in CLASSIC trial. Seven hundred and ninety-four patients with colon and rectal carcinoma were randomly assigned to laparoscopic and open surgery in a 2:1 fashion. Approximately 50 % of the patients had rectal cancer. The conversion rate for the rectal cancer patient was high at 34 %. The circumferential resection margin positivity rates were higher in patients undergoing laparoscopic anterior resection (12 % vs. 6 %). However, the difference was not statistically significant (P = 0.19). At 3-year follow-up, there were undifferentiated in terms of OS, DFS, or local recurrence between laparoscopic AR and open AR patients. Longer follow-up was recommended but not available to date .
CLASSIC rectal cancer
Number of patients
Positive CRM (APR)
Positive CRM (AR)
Number of lymph nodes examined
Although many reports showed promising outcomes for laparoscopic rectal resection, one has to note that most of these surgeons have surpassed their learning curves and have considerable expertise in laparoscopic surgery. It is difficult to generalize these results. More prospective, randomized studies are recommended for accurate comparison between laparoscopic and open approach for rectal cancer. Several other groups have published similarly excellent results, pending the completion of prospective randomized trials addressing laparoscopy for rectal cancer [25–28].
11.3 Surgical Procedures
11.3.1 Preoperative Planning
Preoperative preparation of the patient for laparoscopic colorectal surgery depends on the urgency and magnitude of the procedure, the medical condition of the patient, and the underlying tumor pathology. The surgeon must grasp the exact general medical condition of patient, including any comorbidities that may predispose the patient to cardiopulmonary, cerebrovascular, or musculoskeletal complications. These comorbidities should be corrected or optimized prior to operation. Fluid and electrolyte disorders should be corrected and nutritional states should be optimized. All patients should have bowel preparation to facilitate laparoscopic bowel manipulation. Prophylaxis for deep venous thrombosis shoul be carried out for every patient in the form of heparin and SCDs (brand of antithrombus stretch socks). In the case of rectal cancer, it is important for the surgeon to have all the information regarding tumor location, preoperative tumor stage, and tumor response to preoperative chemoradiotherapy (CRT). Only then can the surgeon decide an operation that will offer patient the best chance for cure, with minimal morbidity and optimal functional results.
In our practice, patients are positioned in a standard way regardless of the type of resection. The patient is positioned and secured on a bean bag which will allow angulation of the OR table intraoperatively, to use gravity as an assistant in holding structures in position. The arms are tucked at the patient’s side. The legs are placed in stirrups, with the knee slightly flexed and the hips straight. The perineum is positioned at the break of the table, which is especially important for left-sided lesions. An orogastric tube and a Foley catheter are inserted. The abdomen is then prepared and draped routinely. The surgeon and assistant usually stand at either side of the patient, while the scrub nurse with the instrument table stand between the patient’s legs.
11.3.3 Surgical Instruments
As laparoscopic surgery continues to advance, the instrumentation also continues to improve with time. It should be noted that all the instruments described below are currently available, both in reusable and disposable format.
220.127.116.11 Laparoscopic Ports
The laparoscopic ports consist of an outer cannula and an inner introducer trocar. The trocar may be sharp or blunt tipped. The ports should be comfortable to use, not easily dislodged during operation, and allow for exchange of surgical instruments efficiently. The port size required reflects the largest instrument that will be introduced through the working port. In most cases, this reflects the stapling devices such as endoscopic GIA, which requires a port size of 12–15 mm diameter.
18.104.22.168 Graspers and Retractors
Bowel graspers are used to hold and manipulate the bowel without tearing it. Therefore, use only atraumatic graspers for this purpose. They should be nonconductive to avoid conduction thermal injury. The coating on the instruments should not be highly reflective in order to avoid impairment of the laparoscopic light detecting system.
There are certain situations that require the use of traumatic graspers. A Maryland grasping forceps has serrated edges and can be useful in grasping small bleeding vessels for coagulation and hemostasis. The laparoscopic Allis forcep is particularly useful for left-sided colectomy. This instrument is used to grasp the anvil of a circular stapler for approximating a left-sided or low rectal anastomosis.
There are several types of retractors, such as the fan retractor, the paddle retractor, or the “snake” retractor, that one can use for retraction of the bowel. However, these retractors are designed for retraction of a solid organ, such as the liver, and they do not work as well for small bowel. In colorectal surgery, we depend on gravity heavily by tilting the table in severe angles to aid in the displacement of the bowel. Most often, this type of maneuver is adequate for the operation. The fan retractor may also be used in the pelvis for retraction of the mesorectum.
22.214.171.124 Energy-Based Dissecting Instrumentation
There are two major types of energy-based dissecting instruments – the Harmonic and the LigaSure. The Harmonic is an ultrasonic-based dissector. The generator generates high-frequency ultrasound waves, which are converted to mechanical vibrations in the functional operating blade. This instrument can be used through the 5 mm ports. The maximum size of the vessels that can be safely divided by the Harmonic is about 5 mm in diameter.
The LigaSure works through a different mechanism by applying pressure and bipolar cautery, generating heat to seal the vessels. This instrument comes in 5 mm and 10 mm diameter. The maximum size of the vessels that can be safely divided by LigaSure is about 7 mm in diameter. The thermal injury to the surrounding tissue is limited to only about 2 mm. In our practice, the LigaSure is routinely used to seal large vessels such as the ileocolic, middle colic, and left colic arteries. We apply double-firing technique to assure hemostasis before division of these large vessels. Although both of these energy sources are effective, we perform most dissection using scissors and monopolar cautery, as we feel this is the most expedient technique for dissection.
11.4 Operative Procedures
11.4.1 Laparoscopic Right Hemicolectomy
126.96.36.199 Step 1. Position and Equipment (Fig. 11.1)
Position (R hemi)
The patient is positioned on a bean bag and secured to the table. After induction of general anesthesia, an orogastric tube and Foley catheter are inserted. The legs are placed in stirrups and the arms are tucked at the patient’s side. We use the atraumatic 5 mm bowel graspers for manipulation of the bowel and use the cautery scissors for dissection. An Endo GIA with vascular load or LigaSure is used for division of the ileocolic artery.
188.8.131.52 Step 2. Port Placement (Fig. 11.2)
Port placement (R hemi)
A 10 mm subumbilical incision is made. The fascia is opened and the abdomen entered using Hasson technique. A purse-string stitch on the fascia and a Rommel tourniquet is used to prevent air leak. A 10 mm port is inserted. The abdomen is insufflated with CO2 to pressure of 15 mmHg. Under direct vision, a 12 mm port is inserted in the left lower quadrant (10 mm if planning to use LigaSure for vessel division). Its location is approximately 3 cm medial and superior to the anterior superior iliac spine. Further 5 mm ports are placed in the left upper, right lower, and sometimes right upper quadrant. For obese patients, one may move the left-sided ports more medially. Make sure at least a hand’s breadth is present between all ports.
184.108.40.206 Step 3. Exposure of the Operating Field (Fig. 11.3)
Exposure of operating field (R hemi)
The assistant now moves to the left side of the patient, standing caudad to the surgeon. The patient is placed in slight Trendelenburg position and rotated to the left. The greater omentum is lifted over the stomach, above the transverse colon. The small bowel is grasped and moved medially so that the cecum, terminal ileum, and the ileocolic pedicle are exposed. Gravitational force alone is often adequate for displacement of the small bowel.
220.127.116.11 Step 4. Identification and Division of the Ileocolic Artery (Fig. 11.4)
Division ileocolic artery (R hemi)
The mesentery of the terminal ileum is grasped and lifted up. This will expose and stretch the ileocolic artery. The peritoneum is opened with cautery scissors along a line between the ileocolic artery and the superior mesenteric artery. Using blunt dissection, the ileocolic pedicle is lifted up. An opening is made with cautery scissors just lateral to the ileocolic artery. Thus a window is created around the ileocolic artery for vessel division. It is important for the dissection to be carried just anterior to the congenital peritoneum, so that the retroperitoneal structures such as the ureter will not be injured and need not be displayed. The vascular division may be done with stapler, energy source, or clips. High ligation of the ileocolic artery is performed for cancer cases.
18.104.22.168 Step 5. Mobilization of the Hepatic Flexure (Fig. 11.5)
Mobilization of hepatic flexure (R hemi)
After ligation of the ileocolic artery, the plane between the ascending colon mesentery and the retroperitoneum is developed with blunt dissection. Laterally the dissection reaches the congenital white line of Toldt. Superiorly the dissection reaches the transverse colon, separating the mesentery off the anterior surface of the duodenum and the pancreas. The patient is then put in reverse Trendelenburg position. The transverse colon is grasped and pulled inferiorly exposing the gastrocolic ligament. Using cautery scissors or other energy-based dissection device, the gastrocolic ligament is divided. Dissection continues laterally and inferiorly. This dissection will connect to the prior retroperitoneal dissection. Laterally, the white line of Toldt is then completely divided right down to the base of the cecum.
22.214.171.124 Step 6. Identification and Division of the Right Branch of the Middle Colic Vessels (Fig. 11.6)
Division of right branch of middle colic artery (R hemi)
In order to easily exteriorize the right colon and tension-free anastomosis, the middle colic artery’s right branch is identified and divided.
126.96.36.199 Step 7. Mobilization of the Ileocecal Junction (Fig. 11.7)
Mobilization of ileocecal junction (R hemi)
The patient is now positioned in Trendelenburg position. The small bowel is placed superiorly and medially. The plane between the mesentery of the terminal ileum and the retroperitoneum is developed with sharp dissection. The dissection is carried medially to the third portion of duodenum. The colon is now completely mobile to the midline.
188.8.131.52 Step 8. Exteriorization of the Specimen (Fig. 11.8)
Exteriorization of specimen (R hemi)
Before extraction of the specimen, the right colon is grasped and tested for its mobility. Hemostasis is assured. All trocar incisions larger than 5 mm (except the subumbilical incision) are closed with a Carter-Thompson suture passer and an 0 Polysorb tie. The cecum is grasped with an atraumatic bowel clamp. Pneumoperitoneum is deflated and subumbilical incision is extended to 3–4 cm. For colon carcinoma, exteriorizing the specimen should always be got through a wound protector (protractor, medium or small) to reduce the risk of port site metastasis. The small bowel, colon, and the mesentery are divided. Specimen is removed to a nearby table and opened to confirm pathology and margin.
184.108.40.206 Step 9. Creation of Anastomosis
An ileocolic anastomosis is fashioned. The mesenteric window does not require closure. It is necessary to check for hemostasis and integrity of the anastomosis and then returned it to abdomen.
220.127.116.11 Step 10. Wound Closure
The midline incision fascia is closed in the standard fashion. The subcutaneous spaces are irrigated, and wounds are sutured with subcuticular 4-0 absorbable sutures.
Use a Rommel tourniquet for the umbilical port.
Use Carter-Thompson with 0 Polysorb tie to close any port >5 mm.
Have endoclip in room.
Use Endo GIA or LigaSure for division of the ileocolic artery.
Use a wound protector for cancer cases. (Protractor, small or medium)
11.4.2 Laparoscopic Sigmoid Hemicolectomy
18.104.22.168 Step 1. Position and Equipment
The patient is positioned on a bean bag and secured to table. After induction of general anesthesia, an orogastric tube and Foley catheter are inserted. The legs are placed in stirrups and the arms are tucked at the patient’s side. The perineum should be at or below the break of the table (Fig. 11.1). Atraumatic 5 mm bowel graspers are used for manipulation of the bowel, and cautery scissors for dissection. An Endo GIA with vascular load or LigaSure is used for division of the inferior mesenteric artery. The laparoscopic Allis forceps is used for firm holding of the anvil of a circular stapler.