Indications, Contraindications, Evaluations
With the exception of rectal cancer cases, laparoscopic surgery can be considered an option for virtually any patient with a colon or rectal condition requiring surgery. With that said, not all patients will be ideal candidates and not all procedures can be performed by all surgeons. All surgeons must find their comfort zone with laparoscopic cases. The initiate to laparoscopy should consider limiting their early practice to right colectomies in patients who are thin and have limited risks of adhesions as well as benign disease process such as polyps or ileocolonic Crohn's strictures. Surgeons with advanced skills may be comfortable doing an entire total proctocolectomy and ileal pouch-anal anastomosis. All of these procedures have been technically described in this chapter to provide a range of procedures that are feasible. In addition to the technical range of possibilities, there is a range with respect to which patients will do well with the laparoscopic approach. As with any laparoscopic approach, for example, there would be some cases where a pneumoperitoneum is contraindicated and others where the disease or technical considerations represent contraindications. Indications and contraindications and pre- and intraoperative evaluations specific to the colon and rectal diseases and patient conditions are provided, followed by focused discussion on oncologic issues relevant to colon and rectal cancer and key points.
The indications for laparoscopic surgery for conditions of the colon and rectum are predominantly the same as those for open surgery (Table 37-2). For inflammatory bowel disease, the list of indications includes symptomatic failure of medical therapy; dysplasia; and presence of strictures, abscess, and fistula. In acute colitis, urgent subtotal colectomy with end ileostomy may be performed initially as a part of a two- or three-stage procedure. Procedures may include strictureplasty, small bowel resection, segmental colonic resection, or proctocolectomy. For diverticulitis, the current American Society of Colon and Rectal Surgeons (ASCRS) guidelines recommend that the decision for elective resection of sigmoid after recovering from acute diverticulitis should be made on a case-by-case basis and recommend the laparoscopic approach in selected patients.3 Large colonic polyps not amenable for resection through the endoscope may be resected through laparoscopic approach. The laparoscopic approach has been proved to produce equivalent outcomes with open resection for localized colon cancer, when oncological principles are practiced. Solitary metastatic lesion in the liver with localized tumor in the colon can also be resected laparoscopically in competent hands.
The laparoscopic approach is preferred in the repair of rectal prolapse. Resection rectopexy and mesh rectopexy both can be performed through the laparoscopic approach. Laparoscopic rectopexy has similar long-term functional outcomes and low recurrence rates.4 As discussed previously, a number of technical challenges are involved in performing laparoscopic rectal cancer resection. Large multicenter trials are going on in North America and Europe to evaluate the outcomes of rectal cancer for laparoscopic approach.
Table 37-2: Indications in Colon and Rectal Diseases ||Download (.pdf)
Table 37-2: Indications in Colon and Rectal Diseases
Ulcerative colitis—refractory disease, dysplasia
Crohn's disease—refractory disease, bleeding, strictures, confined abscess, fistula
Diverticular disease—recurrent, noncomplicated
Colon polyps—not amenable to endoscopic resectiony
Carcinoma colon—localized lesions amenable to 8-cm extraction site
Rectal cancer (in controlled trials)
General health conditions that would contraindicate a minimally invasive approach requiring a pneumoperitoneum typically include any severe manifestation of organ failure (Table 37-3). Patients with severe chronic obstructive pulmonary disease (COPD), reactive airway disease, or other causes of respiratory compromise are usually not tolerant of the abdominal insufflation required for conducting intra-abdominal work. Patients with advanced cardiovascular disease are also typically intolerant of the pneumoperitoneum, as it can restrict the fragile dynamics of cardiac output. Finally, patients with end-organ renal failure and severe electrolyte or fluid disturbances and those with liver failure, ascites, or other sources of bleeding disorders are best served with a more controlled, open approach. At times, these conditions are not appreciated as problematic until the procedure is under way and the anesthesiologist is experiencing difficulties. Accordingly, open lines of communication between the surgeon and the anesthesiologist as well as a willingness to convert to open surgery should be the rule and not the exception.
Less absolute or relative contraindications of laparoscopy include the presence of adhesions, cardiac abnormalities, pulmonary gas exchange abnormalities, chronic liver disease, and obesity. None of these are clear-cut or absolute. For example, patients may have several abdominal scars and have undergone numerous prior procedures even near the site of the anticipated colon resection, but they may not have prohibitive adhesions. Unless we know the patient has prohibitive adhesions, we would approach the case laparoscopically with a cautionary note to the patient that the risk of conversion may be higher than 10–15%. The same can be said for obesity. At times, managing obese patients is facilitated by laparoscopy, such as when the fat is predominantly in the abdominal wall. That being said, some obesity cases cannot be conducted using laparoscopic techniques, for example when the tools will not reach from the port to the site of the surgical resection.
A final category of absolute and relative contraindications includes those specific to the disease under treatment. For inflammatory bowel disease a large phlegmonous mass, complex or large abscess, or complex fistulizing disease are likely not suitable for the bulk of the specimen to be extracted, not to mention the challenges of mobilization. Similarly, a toxic abdomen from sepsis or fecal contamination would not be ideal for laparoscopic surgery. Massive dilation of the large or small bowel could prohibit both intra-abdominal visualization and the safe movement of instruments throughout the abdominal cavity. In cases of cancer, there is little evidence in support of tackling large fixed or recurrent tumors through small incisions. The risk-benefit ratio for large, fixed, and recurrent tumors would likely favor open surgery, although it has never been prospectively studied.
Table 37-3: Contraindications to Laparoscopy ||Download (.pdf)
Table 37-3: Contraindications to Laparoscopy
- Inability to tolerate pneumoperitoneum
- Poor risk for general anesthesia
- Poorly controlled coagulopathy
- Severe systemic disease that is constant threat to life
- Moribund patient, unlikely to survive for 24 h with/without surgery
- Multiple abdominal procedures
- Cardiac abnormalities
- Pulmonary gas exchange abnormalities
- Chronic liver disease
- Morbid obesity
Contraindications in colon diseases
- Large phlegmon or mass
- Complex fistulizing disease
- Tumor infiltrated into adjacent structures (T4 disease)
- Bowel obstruction
- Toxic dilation of the colon
- Significant adhesions
|Contraindications in rectal diseases|
- Large phlegmon or mass
- Complex fistulizing disease
- Locally infiltrative rectal cancer
- Recurrent rectal cancer
- Bowel obstruction
- Toxic dilation of the colon
- Significant adhesions
Preoperative Evaluations Unique to Laparoscopic Surgery
A word must be said about the workup of patients who are intended for the minimally invasive surgical approach. Although the preoperative evaluations are usually the same as for any other laparotomy approach, it is generally advised that the diagnostic tests for the disease and the treatment be as definitive and clear as possible before laparoscopic surgery. The absence of tactile information demands better preoperative assessments than historically considered necessary for open surgery. This was first realized with tumor staging. The traditional approach with open surgery was to palpate the liver at the time of laparotomy to locate metastatic tumor deposits in the abdomen, including such sites as the liver, ovaries, peritoneal cavity, omentum, or retroperitoneal lymph nodes. Current imaging with computerized tomography (CT) has improved to the point that such novel findings at surgery are rare. Surgeons may identify small superficial hepatic metastases or peritoneal tumors at the time of surgery, but this is less common than it was when laparoscopic surgery was initiated in the early 1990s.
In a similar fashion, primary tumors need to be well localized prior to surgery. For the most part this can be accomplished by combining endoscopy with tattooing for small, benign lesions, or with CT imaging for large or malignant neoplasms. Endoscopy, although usually accurate, can be misleading because there are no consistent endoluminal landmarks for identifying colonic location. Early experiences with missed lesions and wrong-site resections brought these lessons forward. For malignant lesions it is often possible to see the mass on staging CT scan; this can be very reassuring for accurate localization. In addition to the preoperative testing, we advise that one never leave the operating room without first confirming that the target lesion has been confidently removed and identified in a specimen. Because colonoscopy can misjudge, anatomic colonic location by more than one colonic segment, this safety measure seems simple and warranted.
For benign conditions, it is equally important to localize the site of diseased bowel and understand the exact extent of disease, that is, complex versus simple fistula, contained mesenteric abscess versus poorly contained complex or perforated abscess. Of course, the size of the specimen will dictate the size of the extraction site. The larger the lesion to be extracted and the larger the incision, the less the benefit there is to the laparoscopic approach. For Crohn's disease, CT enterography may help reveal secondary sites of disease. We would also advise a complete intraoperative assessment of the small bowel in cases of Crohn's disease, especially in cases of stricturing disease.
Intraoperative Evaluations and Reasons for Conversion
Conversion of laparoscopic procedure to open procedure may be required when difficulties are encountered. The reasons for conversion may include unexpected disease, significant adhesions, and inability to identify vital structures such as ureters. It is important to remember that conversion itself is not a complication, even though intraoperative complications necessitate conversion. It should not be viewed as failure but rather as an application of sound surgical judgment. It is probably safer for a surgeon to have low threshold for conversion, because the timing of conversion is critical to reduce not only overall costs but also complications. A decision to convert is best made early in the procedure, thus avoiding an increased risk of complications and reducing operative time. An early decision to convert will ensure that the rates of morbidity and mortality are maintained at acceptable levels.
For patients who are known to have frail tissues from chronic immunosuppression or other systemic conditions with adverse affects on tissues, extra caution should be taken in handling the bowel in particular but other tissues as well during the surgery. It is more difficult to judge the impact of instruments when there is an inability to use tactile information. These cases may benefit from the hand-assisted approach for that reason.
A final note should be made about the use of ureteral stents in minimally invasive cases. In general, we would not use ureteral stents for any case when they are not required in the correlating open surgery. With that said, we have a low threshold for having ureteral stents placed either preoperatively or during surgery when an inflammatory or tumor process obscures the anatomic location of the either ureter. If they are available and make a difference, the lighted ureteral stents can also be used to get a visual sense of location of the ureter.
Oncologic Issues Specific to Laparoscopic Surgery in Colon and Rectal Cancer
Because of the unique controversies that emerged with the introduction of laparoscopic colectomy for cancer, we offer here a section that specifically covers this topic for both colon cancer and rectal cancer. Soon after the introduction of the laparoscopic colectomy in 1991,1 a number of concerns regarding the application of this technique in colon cancer arose, including reports of tumor wound recurrences at trocar sites and tumor extraction sites.5–7 Such reports were frequent enough that national statements were issued recommending a moratorium on laparoscopic colectomy for cancer outside of clinical trials.8 In response, a number of randomized clinical trials were initiated simultaneously in North America, Canada, and in Europe. At least four large prospective, randomized trials have been completed and have reported both short- and long-term outcomes. To date, 3133 patients have been studied by random allocation to laparoscopic versus open surgery and followed for cancer outcomes. These patients are reported from four international trials, including the Barcelona trial9 (219 patients), the COST (Clinical Outcomes of Surgical Therapy) trial10 (872 patients), the COLOR (COlon cancer Laparoscopic or Open Resection) trial11,12 (1248 patients), and the CLASICC (Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer) trial13,14 (794 patients). Short-term results from all four studies confirm equivalent mortality and rates of morbidity between the laparoscopic and the open arms. They also consistently demonstrate reductions in length of hospital stay, time to first feed, and time to first bowel movement. Quality of life, although modest, has also been confirmed.
At least three of these trials, the Barcelona, COST and COLOR trials, have completed 5-year follow-up for the entire cohort of patients. It has been reassuring that these trials have not demonstrated inferiority for the laparoscopic arm with respect to overall survival or disease-free survival. A pooled analysis of all four trials examining 3-year median survival was also conducted and it confirms the same, that is, no difference in overall survival or disease-free survival between the open and laparoscopic arms.15 These data have encouraged the adoption of laparoscopic colectomy for colon cancer in the absence of harm and in the presence of confirmed benefits.
The same is not true for laparoscopic rectal cancer. Indeed, although there have been several clinical trials testing the equivalence of laparoscopic colectomy in the setting of curable colon cancer, there are few studies available to examine the same question in rectal cancer. For rectal cancer, the concerns are different than they were for colon cancer. The initial concern with using laparoscopic techniques in colon cancer focused on the potential for abnormal distribution of cancer cells due to the pneumoperitoneum. It was thought that the pneumoperitoneum created a “chimney effect”16 that caused a focusing of tumor cells at wound sites such as trocar sites or wound extraction sites and increased the risk of tumor implants.17 There was also at least a theoretical risk that it could cause dissemination of tumor cells through abnormal patterns. This has not been borne out in colon cancer and is not considered relevant, therefore, in rectal cancer. What is considered of relevance in rectal cancer is whether laparoscopic techniques can achieve tumor-free margins with the same rate as open surgery.18 Some might argue that the pelvic dissection is facilitated by laparoscopic equipment and access to the deep pelvis with lighting and visualization superior to open surgery in some cases. This has not been proven in diverse practice settings. An additional concern is the ability to achieve distal stapling due to the limits of current instrumentation. These issues are being addressed by a prospective randomized trial conducted by the American College of Surgeons Oncology Group (ACOSOG).19
The ACOSOG Z6051 trial is a multicenter, phase III, randomized clinical trial with the primary objective that laparoscopic-assisted resection for rectal cancer is not inferior to open rectal resection, based on composite primary end point of oncologic factors that are indicative of a safe and feasible operation. The end point of this noninferiority trial is based on detailed and standardized pathologic evaluation of the specimen, including circumferential and distal margins and the completeness of the total mesorectal excision. The primary end point is a novel, surrogate end point for long-term oncologic outcome that reduces both the necessary accrual target of the trial and its time to maturation. The secondary end points include patient-related benefits (blood loss, length of stay, pain medicine utilization), 2-year local recurrence, and quality of life. The eligible criteria for the disease include T3N0M0, T1-3N1M0 adenocarcinoma of the rectum with the lower edge 12 cm or less from the anal verge and completion of 5-fluorouracil (5-FU) or capecitabine-based chemotherapy/radiotherapy in the last 4 weeks. The other patient criteria include age 18 years or greater, ECOG (Eastern Cooperative Oncology Group) performance status 2 or less, body mass index (BMI) 34 or less, no evidence of laparoscopic contraindications, no evidence of systemic disease precluding surgery, nonpregnant, nonlactating, no history of current or previous invasive pelvic malignancy, and no history of psychiatric illness. Surgeon credentialing in both laparoscopic colon and laparoscopic rectal surgery is required for participation in this study. It is based on having completed 20 laparoscopic-assisted resections each of the colon and rectum. The operative reports and the pathology reports of those cases and an unedited videotape of their laparoscopic rectal technique are reviewed by two designated investigators. This noninferiority trial is projected to enroll 650 eligible patients in the United States and Canada. The trial is sponsored by the National Cancer Institute (NCI). Further details and contact information can be obtained from the following website: http://www.cancer.gov/clinicaltrials/ACOSOG-Z6051.