Chapter 5

The role of laparoscopy in the staging of gastrointestinal malignancy has continued to evolve over the last decade. Improvements in noninvasive diagnostic modalities have led to a more selective approach being adopted. Nonetheless, minimally invasive surgical techniques for staging and palliative bypass continue to play an important role in the staging and management of patients with upper gastrointestinal malignancies.

As the multidisciplinary management of gastrointestinal cancer has evolved over the last decade, an accurate extent of disease workup has become essential to treatment planning. Staging procedures should accurately define the extent of disease, direct appropriate therapy, facilitate the use of adjuvant therapies and avoid unnecessary interventions in a safe and cost-efficient fashion.

Recent advances in radiology have provided many noninvasive tools, such as multidetector computed tomographic (CT) scanning, magnetic resonance imaging (MRI) and combined CT with positron-emission tomographic (CT/PET) scanning, that have had a considerable impact on the extent of disease workup. Unfortunately, these modalities may underestimate the extent of disease, with small-volume metastatic disease being appreciated only at open surgical exploration. For over 100 years, laparoscopy has been suggested as a means for identifying such small-volume disease. Recently, a significant amount of data has been produced to suggest that the use of laparoscopy and laparoscopic ultrasound (LUS) in the staging of gastrointestinal malignancies has an impact on overall management.1–7 The aim of laparoscopic staging (LS) is to mimic staging at open exploration while minimizing morbidity, enhancing recovery, and thus allowing for quicker administration of adjuvant therapies if indicated. Proponents believe that LS should be viewed as complementary and not as a replacement for other staging modalities such as CT scanning, MRI, or PET scanning. In simplistic terms, the advantages of laparoscopy are that it allows the surgeon to visualize the primary tumor, determine vascular involvement, identify regional nodal metastases, detect small-volume peritoneal/liver metastases, and obtain tissue for histologic diagnosis.

Laparoscopic staging can be performed immediately before a planned open procedure or at a separate occasion. We have moved to the latter approach in the main because of logistical concerns around the availability and utilization of operating time. Generally the procedure is performed as an ambulatory/outpatient procedure with excellent patient satisfaction.

Laparoscopic staging usually is performed under general anesthesia with the patient positioned supine on the operating table. A warming blanket is placed underneath the patient, who is secured appropriately to the table with padding over the pressure points.

The following operative equipment is considered necessary for the procedure:

1. A 30-degree angled laparoscope either 5 or 10 mm in diameter

2. Five-millimeter laparoscopic instruments, including a Maryland dissector, a blunt-tip dissecting forceps, a cup/biopsy forceps, atraumatic grasping forceps, a liver retractor, and scissors

3. A 5- or 10-mm suction/irrigation device

4. An LUS probe (optional)

In general, we prefer a multiport technique. Access is gained into the peritoneal cavity using a blunt port placed subumbilically by direct cutdown. By ...

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