Minimally Invasive Surgery for Colorectal Cancer - An Update
Minimally Invasive Surgery for Colorectal Cancer - An Update
US Oncological Disease 2006
Published: October 2008
Published: October 2008
Colorectal cancer is still the third most common malignancy in men and women and the second leading cause of cancer death worldwide. There are almost 150,000 cases diagnosed annually in the US, with approximately 57,000 deaths per year. The mainstay of colorectal cancer treatment is surgical resection of the tumor.Traditionally, a colon resection required a midline abdominal incision, a significant stay in the hospital, and a recovery period of up to three months.
Minimally invasive surgical techniques were described as early as 1901, when Kelling placed a cystoscope in a dog. In 1911, Jacobeus laparoscoped a patient with ascites, and in the 1930s, carbon dioxide was used for insufflating the abdomen. It was not until the fiber optic revolution began in the late 1950s that routine surgical use became feasible. This culminated in the 1960s with the report of a laparoscopic tubal ligation. The modern era of laparoscopic surgery began in the 1980s, when high resolution charged coupling devices brought in the era of digital imaging, and in 1987, the first laparoscopic cholecystectomy was performed.
In 1991, five separate authors described a laparoscopic approach to colon resection; however, almost 15 years later, there is still some debate over whether a minimally invasive approach to colorectal cancer is appropriate. This article will review the principles of oncologic resection for colorectal cancer, the benefits and risks of laparoscopic surgery for colorectal cancer, and give an overview of some of the more significant trials published to date.
Principles of Oncologic Resection
Adjuvant chemotherapeutic regimens have improved survival in stage 3 cancers and may be of benefit in some patients with stage 2 cancers as well, but surgical resection is the definitive treatment for colorectal cancer. In general, the goals of an oncologic resection are: taking adequate margins, performing a lymphadenectomy, and performing a high ligation of the vascular pedicles. In addition, a total mesorectal excision is required for low rectal cancers.
For colon cancer, 5cm margins are usually adequate. For a right colectomy, I resect the distal 5cm of ileum as my proximal margin. I routinely take the ileocolic artery and right branch of the middle colic artery. For transverse colon cancers, I perform an extended right colectomy (from ileum to descending colon) and for left colon and sigmoid cancers I ligate the inferior mesenteric artery at the level of the aorta. In addition to cure, sphincter preservation is one of the goals in patients being treated for rectal cancer. For low rectal cancers, a mucosal margin of at least 2cm from the dentate line in conjunction with a total mesorectal excision is required.
