Page 27 - World Journal of Laparoscopic Surgery

Kaundinya Kiran Bharatam

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laparoscopic colectomy or laparoscopic assisted laparoscopic surgery. Such short-term alterations and their
colectomy. Once the rectum is delivered through the long-term implications on tumor recurrence and patient
perineal wound, one of the ports is used on left side to survival though unknown, yet some effects of open surgery
fashion an end colostomy. may be more deleterious than when the operation is
Ideal extent of resection is defined by the removal performed laparoscopically. Wu et al found that in patients
of the blood supply and lymphatics at the level of origin with colonic carcinoma, postoperative leukocyte counts and
of the primary feeding arterial vessel. Furthermore, the leukocyte subpopulations normalized earlier after
lesion should be excised en bloc with tumor-free radial laparoscopic colectomy than after open surgery.
margins (R0) to be considered curative. 4,6
PROSPECTIVE RANDOMIZED CONTROLLED
ISSUES REGARDING LAPAROSCOPIC TRIALS: LONG-TERM RESULTS AND
COLORECTAL SURGERY IN MALIGNANCY OUTCOMES
a. Port-site tumor recurrence: Several theories had been
A review of conducted prospective randomized controlled
proposed for the possible increase in incidence of wound
trials revealed the efficacy of laparoscopic colorectal surgery
metastasis associated with laparoscopic surgery
for malignancy. The United Kingdom Medical Research
including mechanical, metabolic, immunologic and Council Conventional vs Laparoscopic Assisted Surgery in
hematogenous routes of tumor implantation. 7 Direct,
Colorectal Cancer (UK MRC CLASICC; clinical trial no
mechanical contamination from contact between the
ISRCTN 74883561) trial is a randomized clinical study of
excised tumor mass and the wound site was initially
laparoscopic- assisted vs convenctional open surgery in
believed to be a logical etiology; although wound
patients with colorectal cancer. Approximately 794 patients
metastasis have occurred at other port sites, suggesting
were randomized (268 open and 526 laparoscopic) between
8
the role of alternative mechanisms. Despite the benefit 14
July, 96 and June, 2002.
in decreased systemic cell mediated immune suppression
The 3-year overall survival (OS) for all patients was
associated with laparoscopy, CO has been shown to
2 67.8 % with 87 deaths in the open arm and 161 deaths in
result in an acidotic intraperitoneal environment and
the laparoscopic arm. Overall cause of death was similar in
impaired peritoneal macrophage function contributing both arms. There was no difference in 3-year OS for patients
to local tumor implantation. 9-11 But still use of wound
with either colon or rectal cancer. Overall, there was no
protectors and specimen extraction bags to prevent direct
evidence of a difference between the two techniques for
contamination of incision sites and use of a general
any stage of disease, though a nonsignificant trend was
cytotoxic substance like povidone-iodine were excellent
observed for improved 3-year OS after laparoscopic surgery
in preventing port-site incisional tumor implantation after
in patients with Dukes’ A rectal cancers. The 3-year disease
laparoscopy.
free survival (DFS) for all patients was 66.8%. There was
b. Missing hepatic metastatic lesions: Due to the loss of
no difference between the two surgical techniques in
tactile sensation, concern regarding potential to miss
3-year DFS.
hepatic metastatic lesions did arise. The use of
The overall local recurrence rate at 3 years was 8.4%.
intraoperative laparoscopic ultrasonography to effectively
The overall distant recurrence rate at 3 years was 14.9%.
evaluate liver for lesions has eased this issue.
Overall there were 10 wound/port-site recurrences within
c. Technical expertise in laparoscopic procedure.
3 years of randomization. There was one wound/port-site
recurrence in the open arm and nine wound/port-site
SYSTEMIC AND METABOLIC EFFECTS OF
recurrences in the laparoscopic arm. The open wound/port-
MINIMALLY INVASIVE SURGERY
site recurrence was 0.6% and laparoscopic wound/port-
The systemic immune system’s physiological response to site recurrence was 2.5%. Patients developing wound/port-
surgical trauma affects several metabolic pathways, site recurrences tended to have larger tumors (median
producing a state of immunosupression that varies diameter 45 mm) compared to patients without wound/port-
according to the extent of operative trauma. 12 This was site recurrence (median diameter 35 mm), more advanced
suggested by smaller elevations in serum interleukin (IL-6), disease (7 of 10 had Dukes’ C1 or C2 cancers), or evidence
tumor necrosis factor and C-reactive protein (CRP) after of intra-abdominal recurrence (7 of 10).
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JAYPEE