laparoscopic resection for rectal cancer

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  • 1.

2.

  • Laparoscopic colectomy 1 stattempted in early 90s
  • Slow to gain acceptance unlike rapid take-up of lap cholecystectomy
  • Reasons for this include:
    • Steep learning curve
    • Cost
    • Time
    • Concern re oncological soundness
    • Possible port site metastases

3.

  • Sharp dissection between the parietal and visceral layers of the endopelvic fascia
  • Complete excision of rectum & draining lymphaticswith intact visceral envelope
  • Preservation of pelvic autonomics
  • Low local recurrence rates (4% @ 10yrs)

Heald 1986 4. 5.

  • Less blood loss
  • Faster recovery
  • Earlier return of gut function
  • Lower morbidity
  • Magnified view allows precise dissection (pelvic autonomics)

6.

  • Reduced pain
  • Improved cosmesis
  • Decreased adhesions
  • Decreased wound infection rate
  • Reduced immune effect of surgery

7.

  • Steep learning curve
  • Longer operating times (+30% to 50%)
  • Cost
    • Instruments / equipment
  • Port-site recurrence?
  • Oncological soundness compared with open TME?

8.

  • Practical and technical limitations
    • Crowding of instruments in the pelvis
    • Plume can obscure vision
    • Retraction of the rectum can be very difficult
    • Division of the rectum can be difficult
    • Identification of tumour site can be difficult
    • Pneumoperitoneum
      • Gas embolism / decreased venous return

9.

  • Purely Laparoscopic
    • Specimen extraction through natural orifice (ie anus)
    • Hand-sewn colo-anal anastomosis
    • No abdominal incision apart from port sites
  • Laparoscopically Assisted
    • Small incision for specimen retrieval
  • Hybrid
    • Incision to allow rectal dissection ,vessel ligation or anastomosis to be performed in an open fashion
  • Hand-assisted Laparoscopy
    • Combination of both open and laparoscopic techniques through a hand port

10.

  • Optics / image Processing
  • Energy devices (e.g. harmonic scalpel, bipolar energy)
  • New staplers
  • Wound protectors / retractors
  • Hand assist devices
  • Robotics?

11.

  • Smaller, better optical properties
  • Magnification 15-20X
  • Flexible

12. 13.

  • Modified lithotomy (adjustable stirrups)
  • Bean bag or soft mouldable mattress to allow maximum tilt
  • 4-5 cannulas (1/quadrant)
  • CO 2insufflation (12-15mmHg)
  • 30 degree or flexible laparoscope
  • Laparoscope lens cleaner
  • Plume extractor

14. 15. 16. 17. 18. Incision 19. May expedite the mid and upper abdominal steps 20.

  • Pre-operative assessment
    • Can / should it be done laparoscopically?
  • Lateral to medial dissection
  • Full mobilisation of splenic flexure
  • High vascular division
  • Rectal dissection / division / anastomosis

21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32.

  • Evidence is mainly from comparativenon randomised trials
  • Many with small numbers & short follow-up
  • Two randomised trials in the literature looking at lap TME (restorative)
    • (Zhou 2004)
    • MRC CLASICC (Guillou 2005)
  • One RCT on Lap APR
    • (Araujo 2003)

33.

  • Zhou et al (China)
  • Extraperitoneal rectal cancer
  • Lap : open = 82:89
  • No defunctioning ileostomy
  • Short term results only
  • No conversion rate reported

34.

          • Lap Open
  • Mortality(%) 0 0
  • Morbidity (%) 6.1 12.4
  • Leak (%) 1.2 3.4
  • Operation time (min) 120 106
  • Blood loss (ml) 20 106
  • Pain (days) 3.9 4.1
  • First bowel action (days) 4.3 4.5
  • LOS (days) 8.1 13.3(p=0.001)

35.

  • Guillou et al (UK)
  • Multicentre RCT
  • Colon & rectal cancer
  • All surgeons had performed at least 20 laparoscopic resections
  • 794 patients randomized 2:1 for laparoscopic : open surgery
  • 381 patients with rectal cancer (253:128)

Lancet 2005 365:1718-26 36.

  • Conversion 34%(overall fall in conversion rate during the trial)
  • Mortality - all patients (colon and rectal)
    • Intention to treat
      • Open 5%Lap4%
    • Actual treatment
      • Open 5%Lap1%Conversion 9%

Lancet 2005 365:1718-26 37.

  • Complications rectal cancer
    • Intention to treat
      • Open 37%Lap40%
    • Actual treatment
      • Open 37%Lap32%Conversion 59%(p=0.002)

38.

  • Open Lap Conv
  • Anaesthetic time* 135 180 180 mins
  • 1 stBM 6 5 6 days
  • Normal diet 7 6 7 days
  • LOS 13 10 13 days
    • *Rectal and colonic resection

39.

  • Cost intention to treat (mean)
  • Open Lap
  • Theatre 1448 1816
  • Hospital 3713 3359
  • Others 2659 3085
  • Total 7820 8260

Br J Cancer 2006 95:6-12 40.

  • Quality of Life
    • no difference at 2 or 3 months
  • Good quality pathological specimens were received in both groups
    • (nodes and length to vascular tie)
  • Positive CRM rate (anterior resections)
    • Laparoscopic12% (16/129)
    • Open 6% (4/64)

41.

  • CLASSIC group suggest that laparoscopic anterior resection is not justified as a routinue approach due to concerns over:
    • Increased positive CRM rate
    • High morbidity with conversion
  • Learning curve underestimated at the 20 cases used in the trial

42.

  • Araujo et al (Brazil)
  • 28 patients laparoscopic vs open APR
  • Results
    • No conversions
    • Operating time faster in laparoscopic group !
      • 228 vs 284 mins (p=0.04)
    • At mean 4yr follow up
      • 0 recurrences in laparoscopic group
      • 2 local recurrences in open group

Rev Hosp Clin Fac Med Sao Paulo 2003 58:133-40 43.

  • Breukink et al (2006)
  • 48 studies, 4244 patients
  • Poor study methodologies, only 3 RCTs
  • No strong conclusions possible

44.

  • 5-year disease free survival
    • No apparent difference
  • Local Recurrence
    • Most studies found no significant difference
    • Overall

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