Colectomy, Partial – Laparoscopic

Neoplasia

Adenocarcinoma of the colon and rectum is the third most common site of new cancer cases and deaths in men (following prostate and lung or bronchus cancer) and women (following breast and lung or bronchus cancer) in the United States. It was estimated that in 2009, there were 106,100 new cases of colon cancer (552,010 men and 54,090 women) and 40,870 new cases of rectal cancer (23,580 men and 17,290 women) diagnosed. In 2009, 49,920 Americans (25,240 men and 24,680 women) were predicted to die of colorectal cancer. The lifetime risk for developing colorectal cancer in the United States is 5.51% (1 in 18) for men and 5.10% (1 in 20) for women. The risk for developing invasive colorectal cancer increases with age, with more than 90% of new cases being diagnosed in patients older than 50 years. The incidence of colorectal cancer in men from 1998 to 2005 decreased at a rate of 2.8%/year and for women at a rate of 2.2%/year. The death rate for men and women decreased 4.3% annually over the period from 2002 to 2005. There has been a significant increase in 5-year survival rates over the last 30 years. The 5-year survival for colon cancer was 52% from 1975 to 1977, 59% from 1984 to 1986, and 65% from 1996 to 2004. The 5-year survival for Americans with rectal cancer was 49% from 1975 to 1977, 57% from 1984 to 1986, and 67% from 1996 to 2004.

Colorectal cancer occurs in a hereditary, sporadic, or familial form. Hereditary forms of colorectal cancer have been extensively described and are characterized by family history, young age at onset, and the presence of other specific tumors and defects. Familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC) have been the subject of many investigations that have provided significant insights into the pathogenesis of colorectal cancer.

Sporadic colorectal cancer occurs in the absence of family history, generally affects an older population (60 to 80 years of age), and usually presents as an isolated colon or rectal lesion. Genetic mutations associated with the cancer are limited to the tumor itself, unlike hereditary disease, in which the specific mutation is present in all cells of the affected individual. Nevertheless, the genetics of colorectal cancer initiation and progression proceed along similar pathways in the hereditary and sporadic forms of the disease. Studies of the relatively rare inherited models of the disease have greatly enhanced the understanding of the genetics of the far more common sporadic form of the cancer.

The concept of familial colorectal cancer is relatively recent. Lifetime risk for colorectal cancer increases for members in families in which the index case is young (<50 years) and the relative is close (first-degree). The risk increases as the number of family members with colorectal cancer rises ( Table 27-1-1 ). An individual who is a first-degree relative of a patient diagnosed with colorectal cancer before the age of 50 years is twice as likely as an individual in the general population to develop the cancer. This more subtle form of inheritance has been the subject of much investigation. Genetic polymorphisms, gene modifiers, and defects in tyrosine kinases have all been implicated in various forms of familial colorectal cancer.

Laparoscopic Colon Resection

The first laparoscopic colon resections were performed in 1991. The experience gained by surgeons performing laparoscopic cholecystectomy provided the impetus to develop the laparoscopic colon resection. Patients undergoing laparoscopic cholecystectomy had smaller incisions, less postoperative pain, shorter hospital stays, and earlier return to work. These benefits were achieved while preserving the time-honored technical aspects of removal of the gallbladder.

The goals of laparoscopic colectomy are similar to those of laparoscopic cholecystectomy. The technical requirements and principles of colonic resection cannot be compromised in an effort to avoid the detriment of a standard midline incision. Earlier return to physical activity must be reliably provided. In almost all studies investigating the implementation of laparoscopic colon resection for various diseases, patients have been discharged 2 to 3 days earlier than patients treated by open colon resection. Laparoscopic colectomy has not been associated with an increased incidence of complications. It has been suggested that pulmonary and immune system function is better maintained after laparoscopic operation. Body image satisfaction subsequent to the diminished incision size is well documented. The benefits of laparoscopic colon resection have been found in all age groups, including older patients.

The accelerated return of bowel function facilitates earlier discharge from the hospital. The propulsive movement of intestinal content in the nonfed surgical patient is dependent on the migrating motor complex. The migrating motor complex is inhibited by bowel handling, opiate intake, and catecholamine (stress hormone) levels. It is hypothesized that laparoscopic colon resection provides earlier return of bowel function because there is less handling of the bowel, and the benefit of the smaller incision includes decreased catecholamine release and decreased narcotic requirement.

Almost all colon and rectal diseases amenable to surgical treatment are amenable to treatment by a laparoscopic approach. Ileocecectomy for Crohn's disease, right, left, and low anterior colon resection for colon polyps and cancer, ileostomy and colostomy creation and closure, sigmoid resection for diverticulitis, and proctocolectomy with ileoanal J pouch formation for ulcerative colitis are all performed regularly at centers by colon and rectal surgeons who have advanced laparoscopic training. The indications for surgery are the same whether the approach is through a standard incision or by laparoscopic technique. The laparoscopic surgeon essentially performs a proven operation by a technique that reduces the length of the abdominal incision.

There are various nuances of the techniques used by laparoscopic surgeons. Laparoscopic techniques of colon resection invariably involve laparoscopic mobilization of the diseased colonic segments. The postoperative recovery benefit of laparoscopic colon resection is not altered if hand-assisted techniques are used or if bowel division and anastomosis are performed intracorporeally or extracorporeally.

In the first decade after the development of laparoscopic colectomy, there was a concern that laparoscopic colon resection for cancer might not achieve cure rates established by standard oncologic operations. These concerns seemed especially pertinent given a report from Europe in 1994 of a high rate of port site cancer recurrence. As experience has accumulated, port site recurrence appears equivalent to recurrence of cancer in the incision of patients treated by conventional operation.

If the operation is conducted correctly, proximal and distal resection margins and lymph node harvest are the same whether a laparoscopic or conventional incision approach is used. A landmark multi-institutional prospective randomized trial of patients undergoing curative colon cancer resection was reported in 2004, and subsequent experience has confirmed the validity of laparoscopic colectomy as a viable oncologic operation. These studies demonstrated noninferiority of laparoscopic colectomy when compared with operation conducted through a conventional midline incision. In the hands of experienced surgeons, laparoscopic colectomy has proved not only safe but also equally efficacious with regard to survival. The studies also demonstrated decreased pain medicine requirements and shorter hospital stay of patients in the laparoscopic group.