EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
Saleh et al
LAPAROSCOPIC- ASSISTED COLO-RECTAL RESECTION
By
Gamal S. Saleh, Abu-Bakr Mohiey El-Dien,
Ayman M. Hassanin and Ahmed M. Atiya.
Departement of General Surgery, Minia Faculty of Medicine
ABSTRACT:
Laparoscopic resection of the colon and rectum is technically demanding and
requires a great deal of patience and laparoscopic skill. Laparoscopic-Assisted
Colectomy(LAC) may be less time- consuming and comparable to the totallylaparoscopic technique. A twenty patients with colo- rectal malignancy were exposed
to LAC to determine technique feasibility in our department as a restricted- resources
one. In 18 patients( 90%); The procedure was completed successfully and in 2
patients( 10%) conversion to open technique was adopted. We can conclude that LAC
is feasible in our department.
KEY WORDS:
Laparoscopic
Colectomy
Colo-rectal resection.
the colon and rectum but also to
malignant disease (Ludwig and lee,
2005).
INTRODUCTION:
Laparoscopic surgery is the
most significant advancement in the
field of surgery over the past 15 years.
This minimal approach has been
widely embraced and adopted to many
common operations (Gaar, 2004).
Laparoscopic resection of the
colon and rectum is technically
demanding and requires a great deal of
patience and laparoscopic skill (Fowler
et al., 2005).
Minimally invasive surgery is
becoming important in almost every
facet of abdominal surgery. Optical
improvement, miniaturization, and
robotic technology continue to define
the frontier of minimally invasive
surgery (Harrell and Heniford, 2005).
The short term benefits of
laparoscopic colectomy, such as
decreased incidence of pulmonary
complications, faster return of the
bowel function, decreased narcotic
requirements, and faster recovery time,
are now well established (Ludwig and
lee, 2005).
The introduction and rapid
acceptance of laparoscopic cholecystectomy in the late 1980s created a new
era in abdominal surgery and inspired
surgeons to apply laparoscopic
techniques to colo-rectal surgery. Early
success in the laboratory led to the
application of laparoscopic colectomy
for benign diseases such as Crohn's
diseases and diverticulities. As
experience was gained, the techniques
were applied not only to all portions of
However for malignancy, the
long term outcome is more significant
than the benefits obtained in the
immediate post-operative period. If we
can show that the minimally invasive
procedure can give the long term
outcomes in addition to its benefits,
then the procedure has advantages over
conventional open surgery (Leung et
al., 1999).
186
EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
However, the curability of
laparoscopic colectomy for colo-rectal
carcinoma
remains
controversial
because of uncertainties about the
adequacy of resection, the possibility
of cancer cell spread to the port site,
and the lack of data on log term results
(Kojima et al., 2004).
Saleh et al
Minia University Hospital. Operation
time, amount of blood loss and the
need for blood transfusion as well as
conversion to open colectomy and
early post-operative period were
evaluated.
RESULTS:
There were more left-sided than
right-sided resections (16/20, 80%).
Mean Operation time was 197.5 min
and no significant reduction of time
was recorded over the study period.
There were two conversions from
laparoscopic to open procedure (10%).
They had early first flatus 3 days (15days) and bowel movement 2 days (13 days), tolerated solid diet 3 days (1-9
days) and had short hospital stay 7
days (5-12 days) post-operative. Major
blood loss has occurred in 1 patient
(5%) with the need for blood
transfusion. For carcinoma resections,
there were no positive resection
margins in all patients.
The potential for port site
metastasis has been a concern for
laparoscopic treatment of malignant
disease. Most reports of this problem
are anecdotal and provide little
quantitative information (Ludwig and
lee, 2005).
Several randomized studies of
Laparoscopic-Assisted
Colectomy
(LAC) versus conventional Open
Colectomy (OC) for colorectal cancers
are in progress; namely the NCI trial in
USA, the CLASSIC trial in Great
Britain, and the COLOR trial in
Europe, with a total of 1200 patients
recruited in each. Results from these
studies will determine the effectiveness
of laparoscopic surgery for colorectal
cancer (Kojima et al., 2004).
DISCUSSION:
The philosophy of minimally
invasive surgery is to achieve the same
goals of classical open surgery by less
aggressive
means
without
compromising exposure or rationale.
Ensuring that the results of
laparoscopic colo-rectal cancer surgery
are comparable to those of the
conventional standard of open surgery
is critical before the laparoscopic
techniques are widely adopted (Ludwig
and lee, 2005).
Implementation of laparoscopic
techniques in colorectal surgery did not
gain wide acceptance compared to
other abdominal surgeries due to
several reasons related to professional
skepticism as well as socioeconomic
considerations of the community, but
as usual not related to patients
acceptance of the merits of laparoscopy which has been always the main
driving force for adoption of the
technique even before evidence based
decision were available through
controlled randomized studies.
Phillips, 1994 emphasized that
none of these three occasionally
conflicting forces should be allowed to
MATERIALS AND METHODS:
This study included 20 patients
who have one of the indications for
colon resection and each patient was
subjected to full history- taking, full
clinical examination and investigations
as abdominal ultrasound, abdominal
computed tomography, liver function
tests and specific tumor markers. After
evaluation; patients with operable
colonic lesion without acute intestinal
obstruction were exposed to LAC in
187
EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
dominate the ultimate assessment of
what should now constitute best
surgical practice.
Saleh et al
demonstrated that the early benefits of
the laparoscopic approach are realized
and there may be a shorter learning
curve.
Professional concerns centered
around two main considerations, viz
feasibility & outcome of technique.
Jayne DG and colleagues, 2007
found that Successful laparoscopicassisted surgery for colon cancer is as
effective as open surgery in terms of
oncological outcomes and preservation
of Quality of Life (QOL) and our study
has revealed that short term oncological results are similar to results of
open surgery in the literature.
Whereas technological advances
are progressing towards facilitating
problems of exposure (excellent
illumination into inaccessible sites
within the pelvis, superb close up
magnified views, ongoing attempts to
provide stereoscopic vision &different
fan retractors), dissection (ultrasonic
dissector, hand assisted laparoscopy
using special ports), gut resection &
anastomosis (staplers & intra as well as
extra-corporeal knot tying apparatuses)
& specimen retrievel, proper training
of the operating team to these
advanced techniques is mandatory
keeping in mind that several studies
have shown that patients outcome in
colorectal malignant disease is strongly
associated with experience of the
operating team and equipments.
Tan PY and colleagues, 2007
stated that conversion of laparoscopic
anterior resection to open procedure is
associated with higher wound morbidity and a longer hospital stay and
this is competent with our results in
some of our converted cases.
In our study there was a
statistically significant decrease in
hospital stay in comparison to open
surgery in the literature and this is
similar to what was observed by
Salimath J and colleagues, 2007 that
both return of bowel function and
length of stay were statistically
significantly shorter in LAC compared
with those in open colectomy, which
may indicate faster recovery after
bowel surgery in patients undergoing
the laparoscopic approach.
In our study we found that LAC
can be done in centers with limited
capabilities like our Hospital, and this
is similar to what published by Guo
DY and colleagues, 2007 that
laparoscopic colectomy is technically
feasible and safe in small centers, and
can be taken up by relatively laparoscopically naive surgeons without extra
major morbidity/mortality associated
with the learning curve
Hayes JL, Hansen P., 2007
have observed that LAC for cancer
appears to be cost-effective relative to
OC for the lower of the average cost
estimates and is probably not costeffective for the higher estimate.
Expected future reductions in operating
times,
conversion
rates
and
postoperative stays will further
improve cost-effectiveness.
They also stated that LAC
allowed early postoperative recovery
and shorter hospital stay but at the
expense of a longer operation, and this
is similar to our short term results.
Iqbal M and Bhalerao S., 2007
found laparoscopic-assisted colorectal
surgery to be a very useful and
promising technique. Controlled trials
Polle SW and colleagues, 2007
showed that OC has a negative impact
188
EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
on body image and cosmesis as
compared with LAC. Functional
outcome, QOL, and morbidity are
similar for the two approaches. The
advantages of a long-lasting improved
body image and cosmesis for this
relatively young patient population
may compensate for the longer
operating times and higher costs,
particularly for women.
Saleh et al
carcinoma: 3-year results of the UK
MRC CLASICC Trial Group. J Clin
Oncol. 2007 Jul 20; 25(21):3061-8.
8. Kojima M, Konishi F, Okada
M and Naga H: Laparoscopic
colectomy versus open colectomy
for colorectal carcinoma: a retrospective analysis of patients followed
up for at least 4 years. Surgery Today
2004; 34: 1020-.1024.
9. Leung K L, Yiu R Y C, Lai P
B S, Lee J F Y, Thung K H and Lau W
Y: Laparoscopic-Assisted resection of
colorectal carcinoma. Dis Colon
Rectum. 1999 (March); 42(3):327-333.
10. Ludwig K A and Lee W Y:
Laparoscopic partial colectomy in
Mastery of Endoscopic and Laparoscopic Surgery by Soper N J,
Swanstrom L L and Eubanks W S.
Lippincott Williams&Wilkins; 2005 p
436-448.
11. Phillips R.K.S: Expectations of colorectal surgery (benign &
malignant) in Principles & practice
of surgical laparoscopy by PatersonBrown S.&Garden J.,W.B.' Saunders,
London 1994; p 193-209.
12. Polle SW, Dunker MS, Slors
JF, Sprangers MA, Cuesta MA, Gouma
DJ and Bemelman WA. Body image,
cosmesis, quality of life, and functional
outcome of hand-assisted laparoscopic
versus open restorative proctocolectomy: long-term results of a randomized trial. Surg Endosc.2007 Aug;
21(8):1301-7. Epub 2007 May 24.
13. Salimath J, Jones MW, Hunt
DL and Lane MK. Comparison of
return of bowel function and length of
stay in patients undergoing laparoscopic versus open colectomy. JSLS.
2007 Jan-Mar;11(1):72-5.
14. Tan PY, Stephens JH, Rieger
NA and Hewett PJ. Laparoscopically
assisted colectomy: a study of risk
factors and predictors of open
conversion. Surg Endosc. 2007 Dec 11.
REFERENCES:
1. Fowler D L, Sonoda T and
McGinty J J: Laparoscopic subtotal
and total colectomy in Mastery of
Endoscopic and Laparoscopic Surgery
by Soper N J, Swanstrom L L and
Eubanks W S. Lippincott Williams&
Wilkins 2005 P 459-569.
2. Gaar E: Errors in laparoscopic surgery. J Surg Oncol. 2004
Dec l;88(3):153-60.
3. Guo DY, Eteuati J, Nguyen
MH, Lloyd D and Ragg JL. Laparoscopic assisted colectomy: experience
from a rural centre. ANZ J Surg. 2007
Apr; 77(4):283-6.
4. Harrell A G and Heniford B
T: Minimally invasive abdominal
surgeiy: lux et Veritas past, present,
and future. Am J Surg. 2005 Aug;
190(2): 239-43.
5. Hayes JL and Hansen P. Is
laparoscopic colectomy for cancer
cost-effective
relative
to
open
colectomy? ANZ J Surg. 2007 Sep;
77(9):782-6.
6. Iqbal M and Bhalerao S.
Current status of hand-assisted
laparoscopic colorectal surgery: a
review. J Laparoendosc Adv Surg Tech
A. 2007 Apr; 17(2):172-9.
7. Jayne DG, Guillou PJ,
Thorpe H, Quirke P, Copeland J, Smith
AM, Heath RM andBrown JM; UK
MRC
CLASICC
Trial
Group.
Randomized trial of laparoscopicassisted resection of colorectal
189
‫‪Saleh et al‬‬
‫‪EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009‬‬
‫الملخص العربي‬
‫قامت الدراسة على عشرين مريضا يعانون من أحد األمراض التي تستدعي استئصاال‬
‫كليا أو جزئيا للقولون أو المستقيم والذين تم أخذ التاريخ المرضي لهم و إجراء الفحص‬
‫اإلكلينيكي كما تم إجراء فحوصات الدم المناسبة والفحص باألشعة المقطعية‪ .‬وتم إجراء عملية‬
‫االستئصال بمساعدة منظار البطن الجراحي في مستشفى المنيا الجامعي‪.‬‬
‫وقد اعتمدت الدراسة على متابعة الوقت المستغرق في الجراحة وكمية الدم المفقود‬
‫والحاجة إلى نقل دم للمريض واكتمال الجزء الجراحي الخاص باستخدام المنظار‪ ،‬كما اعتمدت‬
‫على متابعة قصيرة األمد للمرضي بعد الجراحة فيما يتعلق بفترة التواجد داخل المستشفى وعودة‬
‫الحركة المعوية وبدء استخدام السوائل واألطعمة‪.‬‬
‫وأظهرت النتائج أن متوسط وقت العملية ‪ 197‬دقيقة‪ ،‬كما لم يتم اكتمال الجزء الخاص‬
‫بالمنظار في حالتين‪ ،‬وتم فقد كمية معتبرة من الدم في حالة واحدة احتاجت لنقل دم‪ ،‬كما تم عودة‬
‫الحركة المعوية وبدء تناول السوائل في غضون ثالثة أيام‪ ،‬وكان متوسط تواجد المريض داخل‬
‫المستشفى سبعة أيام‪.‬‬
‫وقد خلصت الدراسة إلى أنه يمكن استئصال القولون والمستقيم بمساعدة منظار البطن‬
‫الجراحي في المراكز الطبية ذات اإلمكانات المحدودة واالستفادة من مزايا استخدام المنظار‬
‫الجراحي أثناء وبعد العملية الجراحية‪.‬‬
‫‪190‬‬