Minimally Invasive Approaches to Colon Cancer

Laparoscopic colectomy was first described more than three decades ago, following the success of laparoscopic approaches to biliary surgery and appendicitis in the 1980s. Jacobs et al. described their first 20 laparoscopic colectomies for benign and malignant conditions. The paper was fairly modern, with operative times (170 minutes for sigmoid and 155 minutes for right colectomy) and lengths of stay (3 to 5 days for right, 3 to 8 days for sigmoid) comparable to more recent randomized trials. The authors concluded that the procedure “will become as accepted as laparoscopic cholecystectomy.”

Although initial reports were promising, adoption of laparoscopic colectomy for cancer was met with early controversy. A report published by Johnstone et al. in 1996 documented 35 port site recurrences in patients undergoing laparoscopic colon cancer surgery. Other similar reports emerged, creating growing concerns over the safety of laparoscopic colectomy. As a result, a series of randomized trials were undertaken to compare outcomes between laparoscopic and open colectomy for cancer. These trials are described in detail later and represent one of the most comprehensive bodies of literature to evaluate the safety and efficacy of an emerging surgical technique.

Despite the evidence supporting laparoscopic colectomy, widespread adoption has been slow. Moghadamyeghaneh et al. reviewed the National Inpatient Sample between 2009 and 2012 and found that 49% of elective colectomies for cancer were performed laparoscopically, with the rate of laparoscopy increasing over that time period. Other studies have reported similar numbers, with higher rates at academic centers, suggesting that there is still opportunity for increased utilization. Reasons for low adoption rates may include lack of specialized training, low surgeon or hospital volume, underreporting related to reliance on billing codes, or limitations of administrative data in capturing contraindications to laparoscopy.

This chapter will review the trials comparing laparoscopic and open colectomy for cancer and discuss the key technical components of these procedures. It should be noted that laparoscopy is a technique and that it should be used when the surgeon has determined that an equivalent operation can be performed with regard to patient safety and oncologic outcome. Many of the trials included later excluded patients with locally advanced disease, perforation, or obstruction at the time of presentation.