One of the most common cancers in the world US: 4th most common cancer (after lung, prostate, and breast cancers) 2nd most common cause of cancer death (after lung cancer) 2007: 130,000 new cases of CRC 56,500 deaths caused by CRC

1. Η ΛΑΠΑΡΟΣΚΟΠΙΚΗ ΧΕΙΡΟΥΡΓΙΚΗ ΣΤΟΝ
ΚΑΡΚΙΝΟ ΤΟΥ ΠΑΧΕΟΣ ΕΝΤΕΡΟΥ ΚΑΙ ΤΟΥ
ΟΡΘΟΥ
ΔΗΜΗΤΡΗΣ Π. ΚΟΡΚΟΛΗΣ
ΧΕΙΡΟΥΡΓΟΣ
ΔΙΔΑΚΤΩΡ ΙΑΤΡΙΚΗΣ ΣΧΟΛΗΣ ΠΑΝΕΠΙΣΤΗΜΙΟΥ ΑΘΗΝΩΝ
ΕΠΙΜ. Α’
ΑΟΝΑ «Ο ΑΓΙΟΣ ΣΑΒΒΑΣ»

4. ΑΝΑΤΟΜΙΑ

5. ΑΝΑΤΟΜΙΑ

6. ΑΝΑΤΟΜΙΑ

8. Typical sites of incidence and sympoms of colon cancer
ΕΝΤΟΠΙΣΗ - ΣΥΜΠΤΩΜΑΤΟΛΟΓΙΑ

11. A-B right hemicolectomy
A-C extd right hemicolectomy
B-C transverse colectomy
C-E left hemicolectomy
D-E sigmoid colectomy
D-F anterior rection
D-G (ultra) low anterior resection
32025 Anastomosis <10cm from anal verge
32026 Anastomosis <6cm from anal verge
D-H abdomino-perineal resection
A-D subtotal colectomy
A-E total colectomy
A-H total procto-colectomy
A
B C
D
E
F
G
H
© CCrISP Australasia 3rd Edition
Colorectal Major Resections

18. Rectal Ca Radical excision - Left colon
mobilization
• Splenic flexure mobilization
• Sigmoid colon resected
– Quality of circulation is poor
– Functional outcomes as neo-rectum poor
• High ligation of IMA
– Allows mobilization of descending colon
• Ligation of main trunk of left colic

23. Radical excision-Total Mesorectal
Excision(TME)
• Introduced by RJ Heald in 1979
• Use of sharp dissection under vision to mobilize the rectum
rather than the conventional blunt finger dissection
• First series of 112 pts: 5yr LR 2.9% and survival 87.5%
• Local recurrence:
– Conventional surgery: 11.7 - 37.4%
– TME surgery: 1.6 - 17.8%
• Higher leaks rates reported possibly due to:
– Devascularisation of distal rectal stump
– Lower anastomosis
– Other factors: stomas, drains

24. TME - Technique
• Peritoneal incision around rectum
• Rectosigmoid reflected ant and posterior avascular plane
developed using sharp scissor or diathermy dissection under
vision
• Blobbed lipoma should be demonstrated
• Posterior dissection first, then lateral and finally anterior
dissection
• Do not ‘finger hook’ or clamp the lateral ‘ligaments’
• Partial TME to a distance 5cm distal to tumour
• Anterior dissection incorporates Denonvilliars fascia?

25. TME - Technique

26. TME - Fascial envelope

27. TME Specimen

28. TME - Nerve injury
 Preaortic sympathetics during high ligation
 Sympathetics at the pelvic brim during rectal mobilization
 Parasymp(nervi erigentes) and sympathetics during
posterolateral dissection
 No clear lateral ligaments
 Do not hook or clamp these tissues, avoid excessive traction
 Higher rates exp by Japanese with extended lateral LN dissection
 Anterior lateral dissection off the prostatic capsule
 The most likely area of damage, reflected by higher rates of sexual
dysfunction in APR(14-51%) vs AR(9-29%)
 The role of denonvilliars fascia

29. TME - Distal resection margin
• Not clear in the literature
• 5cm preop will expand to 7-8cm on
rectal mobilization
• This will shrink to 2-3cm with specimen
removal and formalin fixation
• Rare for tumour to spread beyond 1.5cm
• Rare reports of poorly diff tumours
having spread 4.5cm distally
• Recommend: 5cm ideally however 2cm
is adequate

30. Reconstruction of Neorectum
• Hand sewn sutured anastomosis
– 1982: Parks and Percy performed the coloanal sutured anastomosis
– ‘Pulled through’ colo-anal anastomosis (Turnbull & Cuthbertson)
• Stapled anastomosis
– Circular stapled technique
– Double stapler technique
• For low and colo-anal anastomosis

31. Reconstruction of Neorectum
 Straight end to end
 Low AR or Coloanal end-to-end anastomosis cause tenesmus, urgency and
incontinence (Anterior resection syndrome)
 Colonic J Pouch
 Increases volume of neorectum
 5 vs 10cm pouches have smaller reservoirs but better evacuation
(Hida et al., Ds Colon Rectum 1996)
 Size is critical to functional outcome, recommend 5-8 cm
 Sigmoid colon should not be used
 Better short term functional results and possible lower anastomotic leaks
compared to end-to-end anastomosis
 Transverse Coloplasty
 New technique introduced in 1999 (Z’graggen et al., Dig Surgery 1999)
 Better in narrow pelvis and limited length of colon
 Long incision closed transversely
 Randomized trial underway comparing to J-pouch

32. Reconstruction of Neorectum
Straight End to End Anastomosis

33. Reconstruction of Neorectum
Colonic J-pouch
Transverse Coloplasty

34. Abdominoperineal Resection
• Described by Sir Ernest Miles 1908
• 1-2 surgeons
• TME rectal dissection
• Anus sutured closed
• Wide perineal dissection, starting from posterior to lateral then anterior
• Anterior dissection can proceed cranio-caudal or vice versa
• SB exclusion - omentum or absorbable mesh
• Drain the pelvic space
• Reduced rates of APR
– Coloanal anastomosis
– Acceptance of smaller margins
– Downsizing by chemoradiotherapy

44. Laparoscopic Colorectal Surgery

45. History
• 1982 Semm performed first
Laparoscopic Appendicectomy
• 1987 Mouret performed first
Laparoscopic Cholecystectomy
• 1992 First UK Laparoscopic Training
centres established

46. Laparoscopic Colorectal Cancer Resections
1990 2003

47. Rewards of Minimally Invasive
Techniques
Operative Time
Cost
Benefits of
New
Techniques
Risk/Effects
Of Anesthesia,
Trauma, Etc.

48. Background
 Laparoscopic colectomy 1st attempted in early 90’s
 Slow to gain acceptance unlike rapid take-up of lap
cholecystectomy
 Reasons for this include:
› Steep learning curve
› Cost
› Time
› Concern for oncological soundness
› Possible port site metastases

49. Preoperative Considerations
• Site (Right and sigmoid easier)
• Tumor size/invasion
• Obesity
• Previous surgery
• Almost always get a pre-op CT (cancer)
• Must talk with patient about need for
conversion to open
• Must be able to find tumor/polyp (tattoo!,
0.5cc India ink in 3-4 sites)

50. Tattoo

51. Preoperative Considerations
Continued
• Can also locate with BE
• Having to do intraoperative colonoscopy is a
flail
– CO2 colonoscopy may be better
• Bowel Preparation
– Utility is debatable, but with laparoscopy it makes
bowel easier to handle

52. Conversion to Open
• 10-25%
– Obesity
– Prior surgery
– Acute inflammation
• Fistula – 50% conversion
– Tumor bulk
• Not a failure
• Early conversion preserves good outcomes
(Wolff, 2007)

53. What difference does it make?
Laparoscopic Colectomy
•It helps you get a job
•Patients like it (thanks to the internet)
•Referring doctors like it
•But what difference does it really make

54. Outcomes
• Ileus – average 1-2 days shorter with
laparoscopy
• Less need for narcotics
• Quicker return of pulmonary function
• Length of stay ~1 day less
• May be influenced by biased expectations
– Who cares?
(Wolff, 2007)

55. Outcomes – Page 2
• Return to work and quality of life
– No statistical change
– Anecdotally improved
• Cost
– Equipment costs and OR time are greater
– May be balanced or outpaced by shorter hospital
stay
• Time – Average 30-60 minutes longer
(Wolff, 2007)

56. Port-Site Metastasis
• Initial concern greatly slowed development of
laparoscopic colectomy
• Not born out in major trials

57. Port site recurrence
• 1-21% incidence
• 3 of 14 patients
• ASCRS registry 1.1%
• Incidence in open wounds = 1%
• Not a problem

58. Specific Trials
• Antonio Lacy
• COST
• COLOR
• MRC CLASSIC

59. Antonio Lacy, et al 2002
• 219 patients
(Lacy et al, 2002)

60. Antonio Lacy, et al
Overall Survival
p=0.16
Cancer Related Survival
p=0.02
(Lacy et al, 2002)

61. Antonio Lacy, et al 2008
(Lacy et al, 2008)

62. COST Trial
Clinical Outcomes of Surgical Therapy Study Group
• 872 patients with colonic adenocarcinoma
• Recurrence
– 16% lap
– 18% open
• Survival
– 86% lap
– 85% open
• Post-operative stay
– 5 days lap
– 6 days open
(COST Study, 2004)

63. COST Trial
Clinical Outcomes of Surgical Therapy Study Group
• 5 year data published October 2007
• Disease-free 5 year survival
– 68.4% Open
– 69.2% Laparoscopic
• Overall survival
– 74.6% Open
– 76.4% Laparoscopic
• Recurrence
– 21.8% Open
– 19.4% Laparoscopic
(COST Study, 2007)

64. COLOR Trial
COlon cancer Laparoscopic or Open Resection
• 1248 patients
• 17% conversion to open
• BMI>30 excluded (because started in 1997)
• Pathologic criteria no different
• Time to GI recovery, 1st BM, hospital stay all
one day less
• Complications were equivalent
(COLOR Trial, 2005)

65. MRC CLASSICC
Medical Research Council trial of
Conventional versus Laparoscopic-ASsisted
Surgery In Colorectal Cancer
• 794 patients
• Pathologic specimens, complications were
similar
• Time to 1st BM 1 day shorter
• Time to diet and discharge similar between
groups
(Guillou et al, 2005)

66. Cumulative Incidence of Recurrence at Any Stage

67. Overall Survival at Any Stage

68. Long – Term Results in Colon Cancer
Lai JH, et al. Br Med Bull 2012

69. Hand Assisted Laparoscopy vs.
“Pure” Laparoscopy
• May reduce learning curve
• May be used “up front” or as a “pseudo-conversion”
• Need to make an incision large enough for the
specimen anyway
• Outcomes similar to laparoscopy, with operative
times usually shorter

70. Applied Medical Gelport

72. Laparoscopic Left Hemicolectomy
Hand Approaches

73. Laparoscopic Left Hemicolectomy
Hand Approaches

74. Hand-assist vs. Laparoscopy
(Targarona et al, 2002)

75. Hand-assist vs. Laparoscopy
(Targarona et al, 2002)

76. Hand-assist vs. Laparoscopy
Marcello et al
• 95 patients - left or total colectomy
• Randomized to HA vs LAP
• Left colectomy
– 175 minutes HA, 208 LAP (p=0.021)
– Flatus 2.5 vs 3 days (p=0.64)
– Length of stay 5 vs 4 days (p=0.55)
• Total colectomy
– 127 vs 184 minutes (p=0.015)
(Marcello et al, 2008)

77. In a comparison of “pure”
laparoscopy and HALS, what does
no significant difference mean?
It means that if you can do it more easily
with one hand in, why not do it?

78. Techniques in Laparoscopic
Colon and Rectal Surgery

79. Room Setup
1) Radiological unit (optional)
2) Laparascopic unit
3) Anaesthetic unit
4) Laparascopic unit – extra
monitors
5) Instrument table
6) Electrocautery
7) Operating table

80. Patient positioning

81. Access and Port Placement

82. Access and Port Placement

83. Trocars

84. Graspers

85. Harmonic Scalpel

86. Endoscopic Circular Stapler ECS29

87. Linear cutter stapler

88. Wound protector

91. Laparoscopic Hemicolectomy
Technique
• Access
• Takedown of previous adhesions
• Mobilization and vascular division
• Intestinal division
• Anastomosis
• Closure of mesenteric defect
– Usually skipped
• Closure

92. Right Hemicolectomy
Laparoscopic Colectomy

93. Port Placement: Right Hemicolectomy

94. Laparoscopic Right Hemicolectomy
Approaches
• Medial-Lateral
• Inferior
• Lateral-Medial
• Top-Down
Largely
Independent
of trocar
placement

96. Don’t burn the duodenum!
Don’t laugh. It’s happened more than once.
(Netter, 1997)

102. • Λαπαροσκοπική Υποβοηθούμενη Δεξιά
Ημικολεκτομή - Δ.Κορκολής: Χειρουργός -
YouTube

103. Left Hemicolectomy
Sigmoidectomy
Low Anterior Resection
Laparoscopic Colectomy

104. Port Placement: Left Hemicolectomy

106. Mobilization of the Sigmoid

107. Identification of the Ureter

108. Division of Mesentery

110. Rectal Resection
Retrorectal
Window

113. Colorectal Anastomosis

117. Laparoscopic Resection
for Rectal Cancer
Should we do it?

118. TME - Gold Standard
• Sharp dissection between the parietal and
visceral layers of the endopelvic fascia
• Complete excision of rectum & draining
lymphatics with intact visceral envelope
• Preservation of pelvic autonomics
• Low local recurrence rates (4% @ 10yrs)
Heald 1986

119. Potential Advantages of Lap TME
• Less blood loss
• Faster recovery
• Earlier return of gut function
• Lower morbidity
• Magnified view allows precise dissection
(pelvic autonomics)

120. Potential Advantages of Lap TME
• Reduced pain
• Improved cosmesis
• Decreased adhesions
• Decreased wound infection rate
• Reduced immune effect of surgery

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

122. Potential Disadvantages
• 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

123. Techniques
 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

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

125. New laparoscopes
•Smaller, better optical properties
•Magnification 15-20X
•Flexible

126. HD imaging

127. Operation Setup
• Modified lithotomy (adjustable stirrups)
• Bean bag or soft mouldable mattress to allow
maximum tilt
• 4-5 cannulas (1/quadrant)
• CO2 insufflation (12-15mmHg)
• 30 degree or flexible laparoscope
• Laparoscope lens cleaner
• Plume extractor

128. Patient Positioning

129. Tilting

130. Theatre Setup

131. Port placement

132. Port placement HALS
Incision

133. Hand-Assisted Laparoscopic
TME
May expedite the mid and upper abdominal steps

134. Technique:
General principles
• Pre-operative assessment
– Can / should it be done laparoscopically?
• Medial to Lateral dissection
• High vascular division
• Full mobilization of splenic flexure
• Rectal dissection / division / anastomosis

135. Left Colon:
Preparation

138. Right side IMA

139. Division of IMA & IMV

140. Left Colon:
Lateral dissection

141. Omental Dissection:
Right to left

142. Pelvic dissection

143. Rectal division

144. Rectal division:
Hybrid / HALS

145. Anastomosis

146. Should We Go There?
Evidence is mainly from comparative
non 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)

147. Laparoscopy: Rectal Cancer
Open Laparoscopic
Patients 89 82
Mean age (years) 45 44
Dukes’ Stage
A
B
C
D
6
8
68
7
5
10
63
4
Prospective, Randomized, Controlled – Short-term outcome
of TME with anal sphincter preservation (ASP)
Zhou, Surg Endosc 2004

148. Laparoscopy: Rectal Cancer
Results of Surgery
Open
(n=89)
Laparoscopic
(n=82)
Distance of Tumor from Dentate (cm)
1.5-4cm
4.1-7cm
56
33
48
34
Distal Margin 1.5-3.5 1.5-4.0
Sphincter preservation 100% 100%
Anastomotic height
Low anterior (>2cm from dentate)
Ultralow anterior (<2cm from dentate)
Coloanal (at or below dentate)
35
27
27
30
27
25
Diverting ileostomy 0 0
Zhou, Surg Endosc 2004

149. Laparoscopy: Rectal Cancer
Open Laparoscopic P
value
Operative time (min) 106 120 NS
Blood loss (ml) 92 20 0.02
Parenteral analgesics (days) 4.1 3.9 NS
Solid intake (days) 4.5 4.3 NS
Hospitalization (days) 13.3 8.1 0.001
Morbidity
Anastomotic leak
12.4%
3
6.1%
1
0.016
Mortality 0 0 NS
Follow-up 1-16 months
Port site mets NA 2
Pelvic recurrence 3 0
Zhou, Surg Endosc 2004

150. MRC CLASICC:
Short term end-points of conventional vs laparoscopic-
assisted surgery in patients with rectal cancer
• 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

151. MRC CLASSIC:
Results
• Conversion 34% (overall fall in conversion rate during the
trial)
• Mortality - all patients (colon and rectal)
– Intention to treat
• Open 5% Lap 4%
– Actual treatment
• Open 5% Lap 1% Conversion 9%
Lancet 2005 365:1718-26

152. MRC CLASSIC:
Results
• Complications – rectal cancer
– Intention to treat
• Open 37% Lap 40%
– Actual treatment
• Open 37% Lap 32% Conversion 59% (p=0.002)

153. MRC CLASSIC:
Results
Open Lap Conv
• Anaesthetic time* 135 180 180 mins
• 1st BM 6 5 6 days
• Normal diet 7 6 7 days
• LOS 13 10 13 days
*Rectal and colonic resection

154. MRC CLASSIC:
Results
• 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

155. MRC CLASSIC:
Results
• 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)
– Laparoscopic 12% (16/129)
– Open 6% (4/64)

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

157. Cochrane Review:
Lap vs open TME for rectal cancer
• Breukink et al (2006)
• 48 studies, 4244 patients
• Poor study methodologies, only 3 RCT’s
• No strong conclusions possible

158. Cochrane Review:
Results
• 5-year disease free survival
– No apparent difference
• Local Recurrence
– Most studies found no significant difference
– Overall <10% (variable follow up)
– Higher for APR (0% - 25%)
– 0% to 6% for sphincter-saving lap TME
– Comparable to open situation (Heald showed 33%
LR after APR)

159. Cochrane Review:
Results
• Perioperative mortality
– No significant difference
• Morbidity
– No apparent difference
– Trend towards lower complications in lap groups
• Anastomotic leak
– No difference

160. Cochrane Review:
Results
• Blood loss
– Reduced with lap TME
• Operative Time
– Significantly longer with lap TME
• Conversion Rate
– Highly variable (0 to 33%)
– Surgeon experience crucial
• Surgical margins
– No difference

161. Cochrane Review:
Results
• Lymph node harvest
– No difference
• Postoperative recovery
– Improved with lap TME
• Quality of life
– Insufficient data

162. Cochrane Review:
Results
• Cost
– Probably increased for lap TME
– Poor data
• Immune response to surgery
– Appears reduced with lap TME

163. Cochrane Review:
Conclusions
• No firm conclusions
• Laparoscopic TME appears to have short term
benefits
• Long term oncological safety requires further
randomized trials

164. Specific Issues
• Port-site hernia
– Rare at 0.3%
– Attention to port site closure
• Port site metastases
– First reported 1993
– Rare at 0.1% overall
– Comparable to wound recurrence in open surgery

165. Specific Issues
• Bladder and sexual function
– Quah (Singapore)
• 80 patients randomised to open or laparoscopic assisted
resection
• Of sexually active males 46% (7/15) decreased function in
laparoscopic group vs 6% (1/15) open
– CLASICC
• Erectile dysfunction in 41% of laparoscopic vs 23% open
(NS)
Br J Surg 2002: 89:1551–6
Br J Surg 2005: 92:1124-32

166. Laparoscopy: Total Mesorectal Excision
(TME) case control study
Breukink, Int J Colorectal Dis 2005
VARIABLE/GROUP LAPAROSCOPIC OPEN P value
OPERATIVE TIME(min) 200 180 0.06
BLOOD LOSS(ml) 250 1000 <0.001
>1000 ml FLUID INTAKE 3 6 0.002
SOLID DIET (days) 4 7 0.046
HOSPITALIZATION
(days)
12 19 0.007
MORBIDITY 37% 51% N/A
ANASTOMOTIC LEAK
(n)
2 2 N/A
MORTALITY(n) 0 1 N/A

167. Laparoscopy: Total Mesorectal Excision
(TME) case control study
VARIABLE/GROUP LAPAROSCOPIC OPEN
CIRCUMFERENTIAL
MARGIN(mm)
3 (2-31) 5 (2-31)
DISTAL MARGIN mm 35 (10-100) 10 (1-30)
NUMBER OF NODES 8 (1-25) 8 (2-20)
FOLLOW UP (months) 14 (2-31) 19 (2-31)
LOCAL RECURRENCE 0 0
DISTANT METASTASIS 5 5
Breukink, Int J Colorectal Dis 2005

168. N Conversion
OR
Time
(mins)
Anastomotic
Technique
Goh, 97 OLAR
LLAR
20
20
-
0%
73
90
Partial TME with double
staple
Leung, 97 OLAR
LLAR
50
50
-
16%
150
196
Partial TME with double
staple
Schwander, 99 OLA/pr
LLA/pr
32
32
-
NS
209
281
LAR 19 Lap 19 Open,
APR 13 Lap 13 Open
Hartley, 01 OLA/pr
LLA/pr
22
42
-
50%
125
180
LAR, APR, Hartmann
Anthuber, 03 OLA/pr
LLA/pr
334
101
-
11%
219
218
TME with colonic J if
<6cm
Breukink, 05 LAR
APR
10
31
NS 195
225
Double stapled
anastomosis
Laparoscopy: Rectal Cancer
Case controlled series for LAR

169. Length of
Stay
LRM DRM Morbidity Morbidity Leak
Goh, 97 OLAR
LLAR
5.5
5
clear
clear
4
4.5
5%
20%
NS 0
0
Leung, 97 OLAR
LLAR
8
6
clear
clear
NS 30%
26%
6%
2%
2%
0%
Schwander, 99 OLA/pr
LLA/pr
21
15
clear clear 31%
31%
0%
3%
0
3%
Hartley, 01* OTME
LTME
15
13.5
0.8
0.65
2.5
4
18%
26%
0%
0%
1
4
Anthuber, 03 OLA/pr
LLA/pr
19
14
DN DN 54%
31%
1%
0%
7%
9%
Breukink, 05 LAR
APR
11
21
NS 3.5 37% 0 5%
Laparoscopy: Rectal Cancer

170. N Conversion OR Time
(mins)
Anastomotic
Technique
Seow-Chen, 97 OAPR
LAPR
11
16
-
NS
100
110
TME
Ramos, 97 OAPR
LAPR
18
18
-
10%
208
229
TME
Fleshman, 99 OAPR
LAPR
42
152
-
21%
209
234
Lap APR with TME
Leung, 00 OAPR
LAPR
34
25
-
NS
166
216
TME
Baker, 02 OAPR
LAPR
61
28
-
25%
NS
NS
?TME
Laparoscopy: Rectal Cancer
Case controlled series for APR

171. Length of
Stay
LRM DRM Morbidity Mortality
Seow-Chen, 97 OAPR
LAPR
8
6.5
clear
clear
3
2
55%
25%
0%
0%
Ramos, 97 OAPR
LAPR
12.9
7.4
NS NS 66%
44%
5.5%
0%
Fleshman, 99 OAPR
LAPR
12
7
+ in 5
+ in 19
NS 27%
33%
0%
0%
Leung, 00 OAPR
LAPR
16
25
NS 1
2
48%
61%
0%
0%
Baker, 02 OAPR
LAPR
18
13
+ in 1 3.2
4.5
-/3%
-/4%
3%
4%
Laparoscopy: Rectal Cancer
Case controlled series for APR

172. Laparoscopic vs. Open Surgery for
Extraperitoneal Rectal Cancer
• 191 consecutive patients
• 98 patients underwent lap resection
• 93 patients underwent open resection
Morino M, Surg Endosc 2005

173. Laparoscopic vs. Open Surgery
for Extraperitoneal Rectal Cancer
Laparoscopic
n = 98
Open
n = 93
P
Mean follow up (months) 46.3 49.7 NS
Conversion rate (%) 18.4
Mobilization (days) 1.7 3.3 < 0.001
Flatus (days) 2.6 3.9 < 0.001
Stool (days) 3.8 4.7 < 0.01
Oral intake (days) 3.4 4.8 < 0.001
Hospital stay (days) 11.4 13.0 NS
Morino M, Surg Endosc 2005

174. Laparoscopic vs. Open Surgery
for Extraperitoneal Rectal Cancer
Laparoscopic
n = 98
Open
n = 93
P
Morbidity (%) 24.4 23.6 NS
Mortality (%) 1.0 2.2 NS
Anastomotic leakage (%) 13.5 5.1 NS
Reoperation (%) 6.1 3.2 NS
Local recurrence (%) 3.2 12.6 < 0.05
Cumulative 5-year survival rate
(%)
80.0 68.9 NS
Disease-free 5-year survival rate
(%)
65.4 58.9 NS
Morino M, Surg Endosc 2005

175. Morino M, Surg Endosc 2005
Laparoscopic vs. Open Surgery
for Extraperitoneal Rectal Cancer
Conclusion
Laparoscopic resection for low and midrectal
cancer is characterized by faster recovery and
similar overall morbidity with no adverse
oncologic effect

176. Long – Term Results in Rectal Cancer
Lai JH, et al. Br Med Bull 2012

177. Conclusions
 Laparoscopic TME is technically challenging
 In experienced hands, lap TME can be performed safely
and confers short term post-operative benefits in terms of
recovery
 Cost and quality of life data are lacking
 Long term oncological outcomes are unknown, but
should be theoretically no worse if TME principles are
followed
 The 3 and 5-year results from the CLASSIC trial suggest
oncological safety.

178. Guidelines
• NICE Guidelines
• ASCRS

180. NICE guidelines laparoscopic
colorectal cancer - August 2006
• Laparoscopic surgery is recommended as an
alternative to open surgery for colorectal
cancer…..
• The surgeon has been trained in laparoscopic
surgery for colorectal cancer and performs the
operation often enough to keep his skills up to
date

182. Who is competent?

183. SpR Training

184. Laparoscopic colorectal fellowships
• St Marks - R Kennedy
• Colchester - R
Motson
• Leeds - PM Sagar

185. Preceptorship
• Training consultants
• Preceptorships - 2-4 cases
• Consultants should have seen >10 live resections
– Courses
– Personal visits

186. Preceptorships
• Preceptors - >100 cases with annual workload of >25
cases
• Audit data - NBOCAP, MDT
• Video material - aide memoire
• ( US - >20 benign cases but BEWARE…)
• www.alsgbi.org

187. • Conversion rate:
– Right sided Lesions: 8%
– Left Sided Lesions: 15%
• Independent Predictors of Conversion
– BMI
– ASA grade
– Type of resection
– Intra-abdominal abscess/fistula
– Surgeon’s experience

188. • Learning Curve:
– Right sided lesions: 55 cases
– Left sided lesions: 62 Cases

189. • Two surgeons
– 721 laparoscopic colorectal procedures
• Learning Curve: 70-80 Procedures
– Operating time
– Conversion rates

205. • http://www.youtube.com/watch?v=rOjdpdtIhB
A