How to prevent port-site metastases in laparoscopic colorectal surgery

Successful resection of port site recurrence of pancreatic ductal adenocarcinoma after laparoscopic distal pancreatectomy

BACKGROUND

There are many reports of port site recurrence after laparoscopic surgery for various types of cancer. However, only two cases of port site recurrence after laparoscopic pancreatectomy have been reported to date. We herein report a case of port site recurrence after laparoscopic distal pancreatectomy.

CASE PRESENTATION

A 73-year-old woman was diagnosed with pancreatic tail cancer and underwent laparoscopic distal pancreatectomy with splenectomy. Histopathological examination revealed pancreatic ductal carcinoma (pT1N0M0 pStage I). The patient was discharged on postoperative day 14 with no complications. However, 5 months after surgery, computed tomography showed a small tumor at the right abdominal wall. No distant metastasis had appeared after 7 months of follow-up. Under the diagnosis of port site recurrence without any other metastases, we resected this abdominal tumor. Histopathological examination showed port site recurrence of pancreatic ductal carcinoma. No recurrence was observed 15 months postoperatively.

CONCLUSIONS

This is the report of successful resection of port site recurrence of pancreatic cancer.

Laparoscopic Excision of Large Wilms Tumor in Children: A Single-Center Experience from a Resource-Challenged Nation

Background: In this study, we aim to review the outcomes of children with Wilms tumor (WT) operated through the minimally invasive surgery (MIS) approach at our center. We also intend to highlight essential surgical steps during laparoscopic excision of large WTs. Methods: This retrospective study included children with unilateral WT who had undergone resection for a period of 4 years, w.e.f. July 2013 to July 2017. Simple maneuvers such as tilting the table in different positions and use of blunt metallic cannula to lift the tumor to access the hilar vessels were used to dissect large WT. An extended lumbotomy incision was used for retrieval of tumor and lymph-node sampling. Results: Eleven patients (male:female = 7:4) of WT, all having stage III disease, had undergone laparoscopic tumor resection at our center during the study period. The median age at presentation was 36 months (range = 17 months-5 years) and the median preoperative tumor volume was 1140 (range = 936-1560) cm³. The average length of the lumbotomy incision was 6.3 (range = 5-8.2) cm. The median hospital stay was 6 (range = 5-10) days. Two children developed complications (port-site recurrence and grade III surgical site infection in one each) during the postoperative period. All cases are long-term survivors after a median follow-up of 86 (range = 56-104) months. Conclusion: This study highlights the feasibility and safety of the removal of large WT through the MIS approach. Problems due to large-sized tumors in children can be overcome by simple maneuvers. Also, adequate lymph node sampling is possible with a suitably placed extended lumbotomy incision for tumor removal.

Comparative single-center study between modified laparoscopic radical hysterectomy and open radical hysterectomy for early-stage cervical cancer

BACKGROUND

Since the release of the LACC trial results in 2018, the safety of laparoscopic radical hysterectomy (LRH) for cervical cancer has received huge attention and heated discussion. We developed modified laparoscopic radical hysterectomy (MLRH) incorporating a series of measures to prevent tumor spillage, which has been performed in our center since 2015.

OBJECTIVE

Present study retrospectively analyzed relevant indicators of MLRH and evaluated disease-free survival (DFS) primarily in the treatment of early cervical cancer compared with open surgery.

METHODS

Patients with 2014 International Federation of Gynecology and Obstetrics clinical stages 1B1 and 2A1 cervical cancer who underwent radical hysterectomy in the gynecological department of our hospital from October 2015 to June 2018 were enrolled retrospectively in this study. Patients were divided into two groups based on the surgical procedure: open radical hysterectomy (ORH) group (n = 336) and MLRH group (n = 302). Clinical characteristics, surgical indices, and survival prognosis were analyzed, including 2.5-year overall survival (OS) rate, 2.5-year DFS rate, recurrence rate, and recurrence pattern.

RESULTS

Compared to the ORH group, the MLRH group exhibited a longer operative time, longer normal bladder function recovery time, less intraoperative blood loss volume, and more harvested pelvic lymph nodes (P < 0.05). No significant differences were observed in postoperative complications, the 2.5-year OS, 2.5-year DFS, and recurrence rate between the two groups (P > 0.05); however, the recurrence pattern was significantly different (P < 0.05). The MLRH group mainly exhibited local single metastasis (7/11), whereas the ORH group mainly exhibited distant multiple metastases (14/16). Stratified analysis revealed that overall survival rate was higher in the MLRH group than in the ORH group in patients with stage 1B1 and middle invasion (P < 0.05).

CONCLUSION

MLRH does not show a survival disadvantage in the treatment of early-stage cervical cancer when compared with open surgery. In addition, MLRH shows a survival advantage in patients with stage 1B1 and middle 1/3 invasion. Considering this is a retrospective study, further prospective study is necessary for more sufficient data support.

TRIAL REGISTRATION

Present research is a retrospective study. The study had retrospectively registered on Chinese Clinical Trial Registry ( http://www.chictr.org.cn/ ), and the registered number is ChiCTR1900026306.

Total Laparoscopic Nerve-Sparing Radical Hysterectomy Using the No-look No-touch Technique

Radical hysterectomy is a standard operation for patients with early-stage cervical cancer. Over the recent decades, laparoscopic radical hysterectomy has been considered an alternative treatment. In 2018, the results of the laparoscopic approach to cervical cancer trial suggested that women with early-stage cervical cancer who underwent minimally invasive surgery for radical hysterectomy had poorer prognosis than those who underwent open surgery. This finding was unexpected, and direct evidence supporting poor prognosis related to minimally invasive radical hysterectomy was not available because the trial was not designed to evaluate the cause of the inferior outcomes. Tumor spillage caused by surgeon-related factors, including squeezing of the uterine cervix and tumor exposure to circulating CO ₂ gas, is considered to be associated with the poor prognosis of patients who underwent minimally invasive radical hysterectomy. We believe that protective maneuver to avoid tumor spillage is the key to improve oncologic outcomes of cervical cancer. Here, we present a procedure of total laparoscopic nerve-sparing radical hysterectomy for early-stage cervical cancer in which techniques, such as the “no-look no-touch technique,” were used to prevent tumor spillage.

Solitary port-site metastasis 42 months after laparoscopic distal gastrectomy for gastric cancer

We report a case of solitary port-site recurrence after laparoscopy-assisted distal gastrectomy for advanced gastric cancer. A 66-year-old man had previously undergone laparoscopy-assisted gastrectomy with regional lymph-node dissection for advanced gastric cancer, which was a poorly differentiated adenocarcinoma invading the subserosal layer with lymphatic infiltration and no lymph-node metastases. He experienced dull pain in the left upper quadrant of the abdomen 42 months after the surgery. On physical examination, erythematous induration of the skin around the scar of the port insertion was observed in the left upper quadrant of the abdomen. Abdominal ultrasonography and contrast-enhanced computed tomography revealed a subcutaneous lesion with a well-defined mass measuring 3.0 cm in diameter located in the left upper quadrant of the abdomen. A skin biopsy revealed a metastatic adenocarcinoma from gastric cancer. Since there was no evidence of further metastatic lesions in other organs, the patient underwent surgical resection of the metastatic tumor arising at the port site. The abdominal wall tumor was resected with a leaf-skin incision and an adequate safety margin, and the inferior border of the tumor reached the muscular layer, which was resected with the tumor. Pathological examination confirmed the diagnosis of a poorly differentiated adenocarcinoma in the subcutaneous tissue with invasion of the muscle layer at the port site. The postoperative course was uneventful; chemotherapy using oxaliplatin plus S-1 was administered, and the patient was in good health with no evidence of the disease for 3 months postoperatively. Although port-site metastasis after laparoscopic gastrectomy for gastric cancer is a rare recurrence form, we should be aware of this issue, and further studies and assessments of additional cases are needed to establish a treatment strategy.

Feasibility and Outcomes of "No-Look No-Touch" Laparoscopic Radical Trachelectomy for Early-Stage Cervical Cancer

Intraoperative tumor manipulation and dissemination may compromise the survival of women with early-stage cervical cancer who undergo laparoscopic surgery. This study aimed to examine survival and obstetrical outcomes related to laparoscopic radical trachelectomy (LRT) with a “no-look no-touch” technique in 40 women. This technique incorporates five measures to prevent tumor spillage and damage to the uterine artery perfusion. Five LRTs were aborted because of positive nodes or positive surgical margins. Compared with those of type III laparoscopic radical hysterectomy, the surgical outcomes of LRT in 35 patients were acceptable: operative time (380 min), estimated blood loss (140 mL), length of hospital stay (15 days), and lengths of excised parametrium and vagina. During follow-up (median, 41.3 months), the 5-year disease-free survival and overall survival were 95.0% (95% CI: 69.5–99.3%) and 100%, respectively. Of the nine patients (26%) who attempted pregnancy, seven conceived (nine pregnancies, 76%). Eight were delivered by term cesarean section, while one was miscarried in the first trimester. Our study suggests that the no-look no-touch technique may be effective in reducing the risk of recurrence and improving obstetrical outcomes during LRT for early-stage cervical cancer.

Feasibility and outcome of total laparoscopic radical hysterectomy with no-look no-touch technique for FIGO IB1 cervical cancer

Objectives

Intraoperative tumor manipulation and dissemination may possibly compromise survival of women with early-stage cervical cancer who undergo minimally-invasive radical hysterectomy (RH). The objective of the study was to examine survival related to minimally-invasive RH with a “no-look no-touch” technique for clinical stage IB1 cervical cancer.

Methods

This retrospective study compared patients who underwent total laparoscopic radical hysterectomy (TLRH) with no-look no-touch technique (n=80) to those who underwent an abdominal radical hysterectomy (ARH; n=83) for stage IB1 (≤4 cm) cervical cancer. TLRH with no-look no-touch technique incorporates 4 specific measures to prevent tumor spillage: 1) creation of a vaginal cuff, 2) avoidance of a uterine manipulator, 3) minimal handling of the uterine cervix, and 4) bagging of the specimen.

Results

Surgical outcomes of TLRH were significantly superior to ARH for operative time (294 vs. 376 minutes), estimated blood loss (185 vs. 500 mL), and length of hospital stay (14 vs. 18 days) (all, p<0.001). Oncologic outcomes were similar between the 2 groups, including disease-free survival (DFS) (p=0.591) and overall survival (p=0.188). When stratified by tumor size (<2 vs. ≥2 cm), DFS was similar between the 2 groups (p=0.897 and p=0.602, respectively). The loco-regional recurrence rate following TLRH was similar to the rate after ARH (6.3% vs. 9.6%, p=0.566). Multiple-pelvic recurrence was observed in only 1 patient in the TLRH group.

Conclusion

Our study suggests that the no-look no-touch technique may be a useful surgical procedure to reduce recurrence risk via preventing intraoperative tumor spillage during TLRH for early-stage cervical cancer.

Rectus Abdominis Muscle Resection for Abdominal Wall Recurrence of Mucinous Adenocarcinoma or Peritoneal Mesothelioma

Aims and Background

Diagnostic technologies which penetrate the abdominal wall in an attempt to definitively diagnose an intraabdominal malignancy by biopsy can contaminate the abdominal wall by cancerous cells. With follow-up these entrapped cancer cells may progress as an abdominal wall recurrence of the disease process. Frequently, laparoscopy is the definitive diagnostic study which results in the abdominal wall cancer progression.

Methods

We examined recurrences within the abdominal wall and attempted to establish a surgical approach to this problem which would maximize a functional result and minimize the incidence of disease persistence within the abdominal wall.

Results

Eighteen patients with abdominal wall recurrence were studied. Laparoscopy port sites resulted in the abdominal wall disease in eight patients, in four the recurrence was at a previous ostomy site, in three it was in a Pfannenstiel incision and in three it was in a McBurney incision site. All of these patients were treated by total resection of the rectus abdominis muscle. This resulted in a complete removal of visible disease that was dissecting along the fibers of the rectus abdominis muscle.

Conclusions

No patients required reoperation for abdominal wall hernia and mesh repair was not used in any of these patients. Disease control within the abdominal wall has been excellent.

Laparoscopy and laparotomy for colorectal cancer: a comparative single-center study

Laparoscopy has been studied as an alternative to laparotomy in colorectal cancer treatment. This retrospective study analyzed postoperative and 2-year oncological outcomes of 205 patients who underwent surgery for colorectal cancer in a Portuguese center. There were no major significant differences between patients submitted to laparoscopy or laparotomy. Operating time was significantly shorter and length of stay significantly longer with laparotomy (135.09 vs 189.29 min [p < 0.001]; 20.32 vs 11.44 days [p < 0.001]). Mean 2-year survival was not significantly different between laparoscopy and laparotomy (overall: 1.96 vs 1.96 [p = 0.866]; disease-free: 1.93 vs 1.89 [p = 0.411]). Port-site metastasis prevalence was 1.56%. In this retrospective study, laparoscopy showed its noninferiority in colorectal cancer treatment, although it should be complemented by controlled prospective studies.

Delayed presentation of port-site metastasis from an unknown gastrointestinal malignancy following laparoscopic cholecystectomy

Port-site metastasis (PSM) is often encountered during laparoscopic surgery in patients with malignancy. We report a 45-year-old woman who presented with a single PSM from papillary adenocarcinoma after undergoing laparoscopic cholecystectomy for calculus cholecystitis. Post cholecystectomy, a diagnosis of chronic cholecystitis was confirmed on histopathology. The patient presented with a mass at the site of epigastric port 28 months after surgery. PSM was suspected on clinical examination, which was supported by findings on computed tomography and further confirmed by fine-needle aspiration cytology of the lump. The patient underwent surgical clearance of the mass, and histopathological examination proved the lesion to be papillary adenocarcinoma. The site of the primary tumour was not detected even after thorough examination. Based on the histopathology report following local surgical clearance, the patient was started on chemotherapy. This case is unusual because of the long delay prior to the presentation of PSM and the unknown primary malignancy.

Pitfalls of laparoscopic colorectal surgery and how to avoid them

SUMMARY Laparoscopic surgery is commonly used for colorectal diseases. Recently, laparoscopy for colorectal carcinoma has increased in use, especially by colorectal surgeons. Laparoscopy is associated with potential pitfalls that pose challenges to the surgeon and team. The identification and management of these pitfalls may not directly parallel those during an open approach. As such, it is essential for the surgeon to have a good working knowledge of how to avoid potential problems and how to best manage them when they do occur. This review highlights common pitfalls of laparoscopic colorectal surgery, as well as offering practical approaches to their management. Technical, patient and surgeon factors are all discussed.

Incisional site metastasis in a patient with cervical carcinoma: a case report and review of the literature

Abdominal wall metastasis either incisional, drain, or port is rather rare in patients treated for cervical carcinoma. We present a case of a patient who underwent an abdominal radical hysterectomy for a moderately differentiated cervical adenocarcinoma stage Ib1 and presented an incisional site metastasis 36 months after her operation. Moreover, we performed a literature search for abdominal wall metastases after radical hysterectomy for cervical cancer, and we present a table of the relative case reports. After our literature search, we clarified that the median time of recurrence was 14 months (range 1.5 month to 45 months). Thirty-three out of 42, 8/42, and 1/42 were squamous, adeno-, and adenosquamous carcinomas, respectively. Wide excision was performed in 30/37 cases of which we have information regarding the treatment option, while 11/37 and 13/37 underwent radiotherapy and chemotherapy, respectively. The possible mechanism of such a metastasis as well as the treatment options is discussed.

Long-term outcomes after laparoscopic colectomy

AIM: To evaluate long-term outcomes in a large series of patients who randomly received laparoscopic or open colorectal resection.

METHODS: From February 2000 to December 2004, six hundred sixty-two patients with colorectal disease were randomly assigned to laparoscopic (LPS, n = 330) or open (n = 332) colorectal resection. All patients were analyzed on an intention-to-treat basis. Long-term follow-up was carried out every 6 mo by office visits. In 526 cancer patients five-year overall and disease-free survival were evaluated. Median oncologic follow-up was 96 mo.

RESULTS: Eight (4.2%) LPS group patients needed conversion to open surgery. Overall long-term morbidity rate was 7.6% (25/330) in the LPS vs 11.1% (37/332) in the open group (P = 0.17). In cancer patients, five-year overall survival was 68.6% in the LPS group and 64.0% in the Open group (P = 0.27). Excluding stage IV patients, five-year local and distant recurrence rates were 32.5% in the LPS group and 36.8% in the Open group (P = 0.36). Further, no difference in recurrence rate was found when patients were stratified according to cancer stage.

CONCLUSION: LPS colorectal resection was associated with a slightly lower incidence of long-term complications than open surgery. No difference between groups was found in overall and disease-free survival rates.

Port site metastases after a laparoscopic abdominoperineal resection of rectal cancer: report of a case

This report describes a case of port site metastases that presented 6 months after a laparoscopic abdominoperineal resection of rectal cancer in a 75-year-old man. A surgical excision was performed to improve stoma function despite disease progression with adjuvant concurrent chemoradiation. Although port site metastases are now reported less frequently, this unfortunate consequence of laparoscopic colorectal surgery for cancer can still occur, and laparoscopic colorectal surgeons should exercise all precautions to prevent its occurrence. This report includes a review of literature on port site metastases.

The use of a wound protector to prevent port site recurrence may not be totally logical

The wound protector has been used widely to prevent port site metastases (PSM). Although port site metastases ties in with poor survival, it is not because of PSM itself, but rather because PSM is a sign of more widespread metastatic disease. Whilst being touted as a method of preventing PSM, it fails to address the bigger issue of preventing intra-abdominal recurrence. Proper surgical technique in tumour handling following rigorous oncological principles, and not just putting in a wound protector is the key to good surgery with low recurrences and excellent survival rates.

Impact of the surgical peritoneal environment on pre-implanted tumors on a molecular level: a syngeneic mouse model

BACKGROUND

We recently demonstrated that a CO(2) pneumoperitoneum at either a high or low IPP has few if any short term effects on peritoneal dissemination when tumors are well established before surgery. The objective of the present study was to evaluate the impact of the surgical peritoneal environment on pre-implanted tumors on a molecular level.

MATERIALS AND METHODS

On day 7, C57BJ6 mice received an intraperitoneal inoculation of a mouse ovarian cancer cell line (ID8). On day 0, mice were randomized into four groups: anesthesia alone, CO(2) pneumoperitoneum at a low (2 mm Hg) or high (8 mm Hg) IPP, or laparotomy. Groups were further subdivided into four groups and a laparotomy was performed to collect pre-implanted tumors on POD 1, 2, 7, or 14. Expression levels of beta-1 integrin, cMet, uPA, uPAR, and PAI-1 mRNA in pre-implanted nodules were measured using real-time PCR.

RESULTS

Expression levels of uPA, uPAR, and cMet mRNA were significantly higher in the laparotomy group than in the control group on POD 1. We detected significantly higher expression levels of uPAR and cMet in the laparotomy group than in the control group on PODs 2 and 7. There were no significant differences in the expression levels of any genes examined among the low IPP, anesthesia alone, and control groups on POD 1, 2, 7, or 14.

CONCLUSION

The impact of a CO(2) pneumoperitoneum at a low IPP on gene expression levels of pre-implanted tumors might be minimal until POD 14 in the present mouse model.

Port site metastases. Curr Opin Urol. 2008;18:185-189. [PMID: 18303541 DOI: 10.1097/mou.0b013e3282f4ab73]

PURPOSE OF REVIEW

The aim of this article is to provide an overview of the incidence, pathophysiology, risk factors and possible methods of reducing the risk of port site metastases following uro-oncological procedures.

RECENT FINDINGS

To our knowledge, 28 cases of port site metastasis have been reported in the urologic literature. There has been an increased interest in the use of intraperitoneal instillation of various tumoricidals in order to reduce the risk of port site seeding.

SUMMARY

The risk of port site metastases remains low, provided that surgeons rigorously adhere to the principles of oncological surgery.

Does laparoscopic surgery offer adequate clearance in rectal cancer?--A discussion

Currently in the UK, the national institute of clinical excellence (NICE), only advocates laparoscopic surgery for rectal cancer as part of commissioned clinical trials. Laparoscopic teaching, training and techniques have evolved greatly and offer many benefits to patients, whilst remaining technically demanding to surgeons still on the slope of the learning curve. Can such minimally invasive techniques be used with the same results as open surgery in the treatment of rectal cancer? Are laparoscopic colorectal surgeons able to achieve the same clearance of tumours and so avoid recurrence at the same rate compared to conventional techniques? The discussion to follow, aims to shed some light on such questions and briefly review some of the literature. If laparoscopic anterior resections and abdominoperineal resections achieve the same results as open procedures, then should these techniques be more widely taught and practised? Surely the peri-operative cost of these laparoscopic procedures does not over shadow the potential outcome from much less traumatic surgery?

Rapidly reversible closure of mini-laparotomy during laparoscopic colorectal surgery

Specimen extraction has been described as the "Achilles heel" of laparoscopic colonic surgery. In most cases, this extraction is performed via a tailored, appropriately placed mini-laparotomy incision. Immediate closure of this mini-laparotomy following specimen extraction wastes operative time and prevents the incision from being used for access later on in the procedure. The use of hand assist devices to allow reversible closure has been reported, not without its own drawbacks including cost and difficulty of use. We hereby describe a technique of creating a rapidly reversible closure of the mini-laparotomy incision using a simple wound protector. This technique is simple, easily reproducible, inexpensive, and effective, leading to time savings in the operating room when applied properly.

Effect of types of resection and manipulation on trocar site contamination after laparoscopic colectomy: An experimental study in rats with intraluminal radiotracer application

BACKGROUND

The etiology and incidence of port-site metastases after laparoscopic surgery for colorectal cancer remain unknown. The purpose of this experimental study was to detect and quantify the amount of contamination at the port-site by means of a method utilizing radiolabelled colloid particles following extra- or intracorporeal laporoscopic resection of cecum.

METHODS

Prior to experimental surgery, we obtained a high concentration of luminal colonic radiotracer activity by per anum application of sulphur colloid molecules labelled with Tc-99m pertechnetate. In three main groups of rats, we either resected a portion of cecum extracorporeally or intracorporeally, or did no resection. Each main group was further divided into two subgroups, in which the manipulations were either autraumatic or traumatic. We excised trocar sites as 2 cm doughnuts after completion of the surgical procedure. We used gamma camera imaging to quantify the amount of radioactive contamination at trocar sites. The background corrected trocar site activity for each rat was calculated. Activities exceeding the maximum background activity were accepted as trocar site contamination.

RESULTS

We detected an overall incidence of contamination in 44% of rats. This rate were 71% and 17% in traumatic and atraumatic subgroups. The resection itself increased the rate and intensity of contamination, as well (p = 0.04). The most intensive contamination was detected in the intracorporeal resection with traumatic manipulation subgroup (p = 0.0007).

CONCLUSIONS

Both the presence of resection and manipulative trauma seemed to be increasing the rate and intensity of the radioactive activity at the trocar site. When traumatic manipulatiun was exercised, the contamination was so intense that the type of resection did not differ. We concluded that our scintigraphic method would be useful in the intraoperative detection of port site contamination by the tumor cells, and that surgeons would take some preventive measures to prevent future port-site metastases.

Laparoscopic total colectomy for colorectal cancers: a comparative study

BACKGROUND

No previous report could be found in the literature comparing laparoscopic and open total colectomy for colorectal cancers, especially synchronous colorectal cancers. This study aimed to compare the short-term clinical outcomes and oncologic results of laparoscopic and open total colectomy or proctocolectomy for colorectal cancers.

METHODS

Between July 1997 and January 2005, six patients with colorectal cancers underwent elective laparoscopic total colectomy or proctocolectomy at the authors' institution. Clinical data for 12 patients who underwent elective open total colectomy or proctocolectomy for colorectal cancers during the same period were prospectively collected and compared.

RESULTS

The median follow-up periods were 43.9 months for the laparoscopic group and 48.2 months for the open group. Conversion to open procedure was required for one patient (16.7%) in the laparoscopic group because of bleeding. The median operative time was significantly longer in the laparoscopic group (427.5 min; range, 280-480 min vs 172.5 min; range, 90-260 min; p = 0.001). The patients in the laparoscopic group required a significantly shorter duration of parenteral analgesia (3 vs 5 days; p = 0.01), but there were no differences in time to first bowel motion, time to resumption of diet, time to full ambulation, and duration of hospital stay between the two groups. Perioperative morbidity rates were comparable between the two groups, and there was no operative mortality. The oncologic results, including number of lymph nodes removed, recurrence rates, and survival rates, were similar in the two groups.

CONCLUSIONS

Laparoscopic total colectomy has short-term clinical outcomes (postoperative recovery and perioperative morbidity and mortality rates) and oncologic results similar to those of open surgery for treating patients with colorectal cancers. Our study has shown that the only advantage of laparoscopic over open surgery is a shorter duration of analgesic requirement, but at the expense of a longer operative time.

Laparoscopic cholecystectomy and gallbladder cancer

Heightened awareness of the possible presence of gallbladder cancer (GBC) and the knowledge of appropriate management are important for surgeons practising laparoscopic cholecystectomy (LC). Long-term effects of initial LC versus open cholecystectomy (OC) on the prognosis of patients with GBC remain undefined. Patients who are suspected to have GBC should not undergo LC, since it is advantageous to perform the en-bloc radical surgery at the initial operation. Since preoperative diagnosis of early GBC is difficult, preventive measures, such as preventing bile spillage and bagging the gallbladder should be applied for every LC. Many port-site recurrences (PSR) have been reported after LC, but the incidence of wound recurrence is not higher than after OC. No radical procedure is required after postoperative diagnosis of incidental pT1a GBC. It is unclear if patients with pT1b GBC require extended cholecystectomy. In pT2 GBC, patients should have radical surgery (atypical or segmental liver resection and lymphadenectomy). In advanced GBC (pT3 and pT4), radical surgery can cure only a small subset of patients, if any. Additional port-site excision is recommended, but the effectiveness of such measure is debated.

Laparoscopic resection of low rectal cancer with a mean follow-up of seven years

The role of laparoscopic surgery in the management of cancer of the rectum remains controversial. The main concern is the risk of port-site metastasis and neoplastic dissemination. The aim of this study was to evaluate prospectively 29 patients who underwent laparoscopic resection with total mesorectum excision for lower rectal carcinoma with a mean follow-up of 7 years. From January 1993 to December 1998, 29 patients with proven low (<10 cm from the anal verge) rectal cancer were operated by a laparoscopic approach. They were followed up at 1-, 3-, and then every 6-month intervals, postoperatively for an average of 7 years. Mean operative time was 157 +/- 46 minutes. The conversion rate was 13.7% (4 cases): 1 for tumor invasion of adjacent structures, 2 for inadequate margins of resection, and 1 for locally advanced cancer. First flatus occurred after 37.3 +/- 11.5 hours, and oral feeding started at 48.3 +/- 23 hours postoperatively. The length of the suprapubic incision for extraction of the specimen was 5.6 +/- 1.7 cm. Hospital stay was 7.2 +/- 3.0 days. There were no deaths. The morbidity rate was 14.8%. Length of the specimen, lateral and distal margins, and the number of lymph nodes resected were comparable to those of an open surgical approach. The average postoperative follow-up was 7 years (5-10 years). The late complication rate was 3.7%. There were no port-site metastases. Five-year recurrence rates were 0%, 22%, and 37% for Duke's A, B, and C cancers, respectively. The 5-year survival rate was 100% for Duke's A, 89% for B, and 50% for C. Laparoscopic resection for low rectal cancer with total mesorectum excision can be performed with the same oncologic principles, low morbidity, and long-term complications. Five-year survival and recurrence rates are comparable to those of open surgery.

Résection rectale pour cancer par laparoscopie avec exérèse totale du mésorectum (ETM). Résultats à long terme d'une série de 179 patients

BACKGROUND

The purpose of this study was to evaluate the outcomes and the five-year survival of 179 consecutive patients with rectal carcinoma operated with a laparoscopic procedure between April 1992 and April 2003.

METHODS

Patients with obstructing, bulky cancers were excluded from this study. Tumor stage was defined according to the TNM classification. Preoperative radiation therapy was offered to T(3) N(0) or N(+) patients (45 Gy). The laparoscopic-assisted technique included total mesorectal excision (TME), primary high vascular ligation, centrifugal dissection of the mesentery, and "no touch" technique. All the N+ patients received adjuvant chemotherapy. The outcomes were defined as five-years recurrence (local recurrence and distant metastasis) and the diseases-free survival. The survival rates were calculated with the Kaplan-Meier test.

RESULTS

There were 108 males and 71 females, median age was 67 (range 39-88). There were 61 upper rectum localizations (34%), 68 middle rectum (38%) and 50 low rectum (28%). Twenty-nine patients required open conversion (16%). Surgical operative morbidity was 24% and medical morbidity was 4%. There were 60 stage I (40%), 25 stage II (16%), 49 stage III (32%), and 16 stage IV (10%). Ninety patients (71%) are alive and disease free, ten (5%) are alive with disease recurrence, and 37 patients (20%) are deceased. Only one case of trocar site implantation occurred after curative resection during an average follow up of 76 months. Five-year observed survival rate were 85% for stage I, 70% for stage II, and 63% for stage III.

CONCLUSION

In our experience laparoscopic rectal resection could be done safely. The oncologic outcome was similar to that of open surgery. Further randomized trials will be necessary to confirm the value of this technique.

Laparoscopic surgery for colon cancer

Acceptance of laparoscopy for the management of oncological disease has been slow due to the increased complexity of the technique, requirement of technological advances, and fears for the oncological safety of the approach. Laparoscopic oncological surgery has a role in the management of oncological patients at all stages of disease. Good evidence exists for the laparoscopic approach being a viable option for colon cancer patients. Current large multicenter trials will report the true outcomes of laparoscopic colon cancer surgery and how it compares with open surgery. This article examines some of the parameters by which laparoscopic colectomy will be judged.

Effect of carbon dioxide pneumoperitoneum and wound closure technique on port site tumor implantation in a rat model

BACKGROUND

The purpose of this study was to evaluate the effects of carbon dioxide (CO2) pneumoperitoneum and wound closure technique on port site tumor implantation.

METHODS

A standard quantity of rat mammary adenocarcinoma (SMT2A)was allowed to grow in a flank incision in Wistar-Furth rats (n = 90) for 14 days. Thereafter, 1-cm incisions were made in each animal in three quadrants. There were six control animals. The experimental animals were divided into a 60-min CO2 pneumoperitoneum group (n = 42) and a no pneumoperitoneum (n = 42) group. The flank tumor was lacerated transabdominally in the experimental groups. The three wound sites were randomized to closure of (a) skin; (b) skin and fascia; and (c) skin, fascia, and peritoneum. The abdominal wounds were harvested en bloc on postoperative day 7.

RESULTS

Histologic comparison of the port sites in the pneumoperitoneum and no-pneumoperitoneum groups did not demonstrate a statistically significant difference in tumor implantation for any of the closure methods. Evaluation of the closure techniques showed no statistical difference between the pneumoperitoneum group and the no-pneumoperitoneum group in the incidence of port site tumor implantation. Within the no-pneumoperitoneum group, there was a significant increase (p = 0.03) in tumor implantation with skin closure alone vs all three layers. Additionally, when we compared all groups by closure technique, the rate of tumor implantation was found to be significantly higher (p = 0.01) for skin closure alone vs closure of all three layers.

CONCLUSIONS

This study suggests that closure technique may influence the rate of port site tumor implantation. The use of a CO2 pneumoperitoneum did not alter the incidence of port site tumor implantation at 7 days postoperatively.

Role and limitations of laparoscopic liver resection of colorectal metastases

BACKGROUND

The current experience of laparoscopic liver resection is reviewed focusing on the role and limitations of resection of colorectal metastases. Surgical technique, outcome, and the main controversies regarding the procedures are described.

METHODS

Current literature on laparoscopic liver resection is reviewed based on reports identified following a specified PubMed search.

RESULTS

Available evidence indicates that laparoscopic liver resection can be made safely in selected patients with comparable duration of surgery, blood loss, tumour clearance, and mortality to that of open resection. Tumours localised peripherally in the left lateral segments of the liver or in segments IV-VI seem to be best suited for laparoscopic resection. The laparoscopic approach may be beneficial to the patients as compared to conventional resection but randomised trials are pending. Laparoscopic resection of colorectal liver metastases is described in a small number of patients only. The long-term outcome following such resections is not adequately documented.

CONCLUSIONS

Laparoscopic liver resection is a promising technique with a comparable short-term outcome to that of open procedures but with the potential advantages of minimal invasive treatment. The technique should be further evaluated in properly designed trials. Laparoscopic resection of colorectal liver metastases should not be performed on a regular basis until long-term results are defined.

Port site metastases

BACKGROUND

Concerns about port site metastases have limited the application of minimally invasive surgery for intra-abdominal malignancies. The purpose of this review article was to summarize the current literature regarding port site metastases.

METHODS

A Medline search identified >100 articles in English published during the last 15 years regarding the history, incidence, etiology, and prevention of port site metastases. These articles were reviewed and are summarized.

RESULTS

The incidence of port site metastases, initially thought to be as high as 21%, is now thought to be closer to the incidence of wound metastases after open surgery. Multiple etiologic factors have been studied including direct wound contamination, surgical technique, effects of carbon dioxide pneumoperitoneum, and changes in host immune response. Various preventive measures have been proposed.

CONCLUSIONS

Port site metastases are a well-documented and devastating complication after laparoscopic resection of intra-abdominal malignancies. Although the etiology is not yet understood, a number of factors are contributory. All efforts should be made to prevent port site metastases.

Laparoscopic colon resection for colon cancer

INTRODUCTION

Laparoscopic colon resection for cancer is as yet an unproven operation. This review article summarizes current data on the topic.

METHODS

A Medline review identified articles published since 1990 summarizing patients with potentially curable colon cancer who underwent a laparoscopic-assisted colon resection. Only articles that were randomized or had a control group with historical or matched open cases were used.

RESULTS

Very few prospective randomized controls exist. Several clinical trials are under way with one completed. Data thus far support some patient benefits with a laparoscopic approach. No differences in morbidity, oncologic data, or survival appear to exist.

CONCLUSIONS

The results of ongoing clinical trials are still needed to further evaluate the role of laparoscopic assisted colon resection in patients with potentially curable colon cancer.

Laparoscopic versus conventional open resection of rectal carcinoma: A clinical comparative study

AIM: To evaluate the feasibility of laparoscopic resection of rectal carcinoma and to compare the short-term outcome of laparoscopic procedure with conventional open surgery for rectal cancer.

METHODS: Thirty-eight patients with rectal cancer were included in a prospective non-randomized study. The patients were assigned to laparoscopic (n = 18) or open (n = 18) colorectal resection. Case selection, surgical technique, and clinical and pathological results were reviewed.

RESULTS: The operative time was longer in laparoscopic resection group (LAP) than in open resection group (189 ± 18 min vs 146 ± 22 min, P < 0.05). Intraoperative blood loss and postoperative complications were less in LAP resection group than in open resection group. An earlier return of bowel motility was observed after laparoscopic surgery. The overall postoperative morbidity was 5.6% in the LAP resection group and 27.8% in open resection group (P < 0.05). No anastomotic leakage was found in both groups. The pathologic examination showed that the length of the resected specimen, the mean number of harvested lymph nodes in laparoscopic resection group were comparable to those in open resection group.

CONCLUSION: Laparoscopic total mesorectal excision (TME) for rectal cancer is a feasible but technically demanding procedure. The present study demonstrates the safety of the procedure, while oncologic results are comparable to the open surgery, with a favorable short-term outcome.

[Surgical therapy of rectal carcinoma]

Total mesorectal excision (TME) has gained a revolutionary impact on the surgical therapy of rectal cancer within the last 2 decades, providing superior local tumor control in comparison to conventional resection. Consequently, 85% of rectal carcinomas can be resected by sphincter-preserving surgery without compromising either oncologic radicality or continence. With the introduction of TME, local recurrence rates have been reliably decreased below 10% after curative resection. Surgical dissection along the connective tissue space between rectal and parietal pelvic fascia with complete mesorectal excision results in reliable excision of all relevant lymphatic pathways with preservation of continence and sexual function. Complete removal of a TME specimen is mandatory in carcinomas of the middle and lower third of the rectum. Both removal of the complete TME specimen and careful pathologic examination of the circumferential resection margin have decisive significance. An additional pelvic lymphadenectomy with the potential risk of increased morbidity does not improve prognosis. As a spread of tumor distally along the bowel wall rarely exceeds a few centimeters, a distal resection margin of 1-2 cm is oncologically sufficient in sphincter-saving procedures without compromising prognosis. Taken together, the convincing results of TME provide a rationale for using TME as the dissection policy of choice to resect rectal cancers in the distal two-thirds of the rectum, despite the absence of direct evidence from prospective randomized trials. The question whether laparoscopic curative resection for rectal cancer is oncologically adequate cannot be definitely answered to date, as results of randomized studies are currently missing. However, the preliminary results of laparoscopic resection for rectal cancer provided by centers are promising.

Management of port-site metastasis after laparoscopic surgery for ovarian cancer

OBJECTIVE

The purpose of this study was to define the clinical features and long-term prognosis of port-site metastasis after primary laparoscopic surgery for ovarian cancer.

STUDY DESIGN

All the patients with epithelial ovarian cancer or borderline malignancy who had undergone primary laparoscopic surgery at our institution were reviewed. The clinicopathologic parameters, flow cytometric parameters, p53, p27, bax, HER-2/neu, and bcl-2 by immunostaining, presentation of port-site implants, management of the individual patient, and long-term outcome were analyzed. CANCERLINE and MEDLINE (1960-2002) were searched for related papers.

RESULTS

Between 1993 and 2001, of the 31 patients with epithelial ovarian cancer or borderline malignancy who underwent primary laparoscopic surgery at Chang Gung Memorial Hospital, 6 (19.4%) had port-site metastasis. The other 2 patients were referred after port-site metastasis. Tumors with port-site recurrences had higher S-fraction than those without (median: 18.2% vs 9.9%, P =.003; relative risk ratio: >15.5% vs <or=15.5% = 38.33; 95% CI, 3.3-449.2). Those patients who have port-site metastasis develop during chemotherapy (n = 2) or after adequate chemotherapy had been given (n = 2) all died of cancer. Two patients have been currently alive without disease, the tumors of whom were p27-positive and p53-, HER-2/neu -, bcl-2-negative.

CONCLUSION

Port-site metastasis after laparoscopic surgery, during chemotherapy or when adequate chemotherapy has been given, is usually associated with poor outcome. Further investigations are necessary to define the mechanisms and effective management to prevent and treat this serious complication.

Specimen retrieval in laparoscopic colon surgery

In the past decade, for benign as well as malignant colon diseases, minimally invasive surgery has gained more and more importance in colon surgery. Specimen retrieval after colonic resections is difficult due to the large size of the specimen usually resected. To date there is no standardized retrieval technique for the different procedures. Four incision sites are common for transabdominal specimen retrieval: left or right lower quadrant transrectal portside incision; periumbilical midline incision, and transverse suprapubic incision. Perineal incisions are used for retrieval following low anterior resection or abdomino-perineal extirpation. Three major complications are described in the literature: wound infection (0-9%); hernias (0-2%), and incision site recurrence (0-1.3%). There are no significant differences between the different incision sites with regard to the occurrence of complications. In laparoscopic surgery for malignant diseases retrieval is usually performed using a plastic bag, whereas retrieval can be performed hand-assisted without a bag during surgery for benign diseases. Wound edge protectors are recommended by several authors, yet there is no standard system which is accepted broadly. In conclusion, specimen retrieval in laparoscopic colon surgery is not standardized. The morbidity rate for specific retrieval complications ranges between 0 and 9%, yet there are no randomized controlled studies or evidence-based data regarding different retrieval approaches and systems.

Tumor cell dissemination during laparoscopy: prevention and therapeutic opportunities

Port-site recurrences (PSRs) are abdominal wall recurrences that occur in the subcutaneous tissue within a trocar site after cancer laparoscopy and are not associated with peritoneal carcinomatosis. In order to develop PSRs, viable tumor cells must be liberated from the primary tumor, be transported to a wound, and find there a favorable environment for growth. The short clinical delay in the occurrence of PSRs and their size suggest massive cell seeding into the abdominal wall. Traumatic handling of the tumor, slipping of trocars, liquid projection, as well as poor extraction techniques can all cause implantation of malignant cells into the subcutaneous tissue. Such contact can also occur postoperatively if the trocar channels remain open. Some histologies (e.g. gallbladder adenocarcinoma), the presence of ascites and advanced tumor stage are risk factors for PSRs. Further conditions--including the use of gas--might also play a limited role. The first preventive measure is the correct indication for a laparoscopic approach. Several techniques have been demonstrated to prevent PSRs in the animal model: (a) fixation of trocars to the abdominal wall; (b) prevention of leakage; (c) careful specimen handling; (d) reducing trauma to the abdominal wall; (e) specimen isolation before extraction from the abdominal cavity; (f) trocar-site irrigation with a cytotoxic solution, and (g) closure of peritoneum. Further innovative therapies are currently under investigation. In the clinical setting, correct indication, surgical expertise and application of prophylactic measures seem to be the best way to prevent the occurrence of PSRs.

Port site metastases in urological laparoscopic surgery

PURPOSE

Laparoscopic surgery is rapidly gaining widespread acceptance among urologists, including extensive application in malignant conditions. However, untoward occurrences of port site metastases have not eluded to urological applications. This up-to-date review on port site metastases in urology delineates possible contributing factors and describes techniques to prevent it.

MATERIALS AND METHODS

We comprehensively reviewed published experimental and clinical studies with special emphasis on the incidence, pathophysiology and prevention of port site metastases.

RESULTS

Nine cases of port site metastases after urological laparoscopy have been described in clinical and experimental studies. Etiological factors include natural malignant disease behavior, host immune status, local wound factors, laparoscopy related factors such as aerosolization of tumor cells (the use of gas, type of gas, insufflation and desufflation, and pneumoperitoneum) and sufficient technical experience of the surgeons and operating team (adequate laparoscopic equipment, skill, minimal handling of the tumor, surgical manipulation and wound contamination during instruments change, organ morcellation and specimen removal).

CONCLUSIONS

Port site metastases is a multifactorial phenomenon with an as yet undetermined incidence. The problem is influenced to some extent by surgeon and operating team experience and, therefore, it could be partially prevented. The suggested preventive steps are avoiding laparoscopic surgery when there are ascites, trocar fixation to prevent dislodgment, avoiding gas leakage along and around the trocar, sufficient technical readiness of the operating team (adequate laparoscopic equipment and technique, minimal handling and avoiding tumor boundary violation of the tumor), using a bag for specimen removal, placing drainage when needed before desufflation, povidone-iodine irrigation of instruments, trocars and port site wounds, and suturing 10 mm. and larger trocar wounds.

[Colorectal cancer: 74 patients treated by laparoscopic resection with a mean follow-up of 5 years]

OBJECTIVE

The aims of this study were to analyse the results and long term outcome in a prospective non randomised trial of 74 patients treated by laparoscopic colo-rectal resection for cancer, and to determine wether survival and recurrence are or are not compromised by an initial laparoscopic approach.

PATIENTS AND METHODS

Seventy-four patients with colo-rectal carcinoma were included in a prospective trial and treated by laparoscopic resection. All patients were reviewed at 1, 3, and 6 months interval. A median of 5 years follow up was available. Forty-eight patients (65%) had more than 3 years of follow up.

RESULTS

Six conversions (8.1%) were necessary: 2 for tumor invasion of adjacent organs, 2 for limited margin resection in lower rectal tumors, 1 for small bowel injury and 1 for obesity. After surgery, passing flatus occurred at 34.3 +/- 16.7 h and oral intake could be reinstaured at 42.6 +/- 22 h. Mean postoperative stay was 8.2 +/- 3.4 days. No death occurred. The overall morbidity was about 13.5%. The rate of late complications was 5.4%. Two port site metastasis (2.6%) were seen in locally advanced carcinoma. Recurrence rate at 5 years was 0% for Dukes A, 20% for Dukes B, 39.2% for Dukes C. Survival rate at 5 years was 100% for Dukes A, 80% for Dukes B, and 60.7% for Dukes C. These results are similar to those of conventional open surgery.

CONCLUSION

Laparoscopic colorectal resection for cancer can be performed safely, with a low morbidity and rare late complications. Long term follow up (5 years) assessment shows similar outcome compared with conventional surgery.

Laparoscopic Versus Open Surgery For Colorectal Carcinoma

The role of laparoscopic resection in the management of colorectal cancer is still unclear. It has been shown that laparoscopic colectomies can be accomplished with acceptable morbidity. Major concerns are port-site recurrences and neoplastic dissemination. The aims of this study were to compare perioperative results and long-term outcomes in a prospective, nonrandomized study of patients treated by laparoscopic versus open colorectal resection for cancer. In particular, the effects of an initial laparoscopic approach on survival and recurrence were examined. One hundred fifty-seven patients with colorectal carcinoma were included in the prospective trial: 74 underwent laparoscopic resection and 83 underwent conventional open surgery. The two groups were comparable in terms of characteristics, demographic data, stage of disease, and use of adjuvant or palliative chemoradiotherapy. All patients were observed at 1.3- and 6-month intervals. The median duration of follow-up was 60 months (range, 10-125 months). The mean operating time was significantly longer in the laparoscopic group. Six conversions (8.1%) were necessary. The passage of flatus and the restarting of oral intake (P = 0.0001) occurred earlier in the laparoscopic surgery group than in the open conventional surgery group. The mean postoperative stay was significantly shorter in the former group (P = 0.005), as was the length of the scar (P = 0.001). There were no deaths in either group. The overall morbidity was significantly lower (13% versus 33.7%; P = 0.001) in patients treated laparoscopically. No significant differences were observed between the groups in the length of specimens, the size of the tumor, or the number of nodes removed. Late complications were more frequent after open resection (12% versus 5.4%; P = 0.01). Two port-site metastases (2.6%) were seen in stage III and IV locally advanced carcinoma. There was no significant difference in recurrent disease between the groups (24.3% versus 25%) during the 60-month follow-up. Stage-for-stage comparisons showed that disease recurrence rates and crude death rates were comparable.