Tumour cell wound distribution after colectomy in a porcine model

Laparoscopic Pelvic and Paraaortic Lymphadenectomy in Gynecologic Oncology

In the early 1990s, different authors independently developed techniques for pelvic and paraaortic lymph node sampling. Since then, laparoscopic lymphadenectomy has been demonstrated to yield the same number of nodes when compared with the laparotomic approach. Only one microscopically involved lymph node was lost at laparoscopic lymphadenectomy when a laparotomic control followed immediately after. It seems bleeding, which is the most serious perioperative complication, is more common during laparoscopic lymphadenectomy than during laparotomy; however, the incidence will decrease with experience of the surgeon. The laparoscopic procedure does not seem to influence negatively the survival of patients with early stage endometrial and cervical cancer. There does not seem to be a significant reduction in overall hospital charges for laparoscopic surgery in oncology, but patients who undergo laparoscopic surgery recover significantly sooner than those who undergo laparotomy.

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.

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.

Laparoscopic surgery for colorectal carcinoma. an overnight victory?

Laparoscopic surgery became popular in the early 1990s. Cholecystectomy was the first 'victim' conquered by the new technique and laparoscopic cholecystectomy became the gold standard operation for gallbladder stones. Laparoscopic colorectal surgery was then attempted, for both benign and malignant disorders. After a short period of enthusiasm, alarming reports were published on laparoscopic surgery for malignant disease. The occurrence of so called 'port-site' metastases (PSM) led to a reduction in the use of the minimal invasive technique. In addition, the duration of the operations was criticised, as well as the limited beneficial effects (if any) and the possible violation of oncological surgical principles. The pros and cons of this new technique during its introduction are discussed, with focus on problem areas such as port-site metastases, surgical learning curve as well as beneficial effects. The current status of several comparative studies evaluating the laparoscopic technique is discussed leading to the conclusion that a basis for further research exists and therefore cautious progress is warranted.

Description of an intraperitoneal tumour xenograft survival model in the pig

AIMS

Experimental animal studies are necessary if the results of minimally invasive oncological surgery are to be improved. In particular the influence of surgical technique on tumour implantation needs further assessment. Small animals such as rodents are inappropriate for such laparoscopic surgical studies. There is a requirement for another animal tumour model with animals greater in size.

METHODS

Accordingly we developed an intraperitoneal tumour xenograft survival model using the domesticated pig. After creating a 12 mmHg pneumoperitoneum, 10(7)human HeLa cells were injected into the peritoneal cavity of nine non-syngeneic animals to induce tumour xenograft. Resection of the sigmoid colon using four trocars and a transanal double-stapling technique was performed. The mean operating time was 69 min. No signs of post-operative pain symptoms were observed, and all the animals survived the procedure and gained weight. After 4 weeks, the animals were sacrified and all incision sites and anastomoses were excised.

RESULTS

Immunohistochemical staining with antihuman pancytokeratin antibodies confirmed tumour implants in 25 out of 36 port-sites (63.8%). No peritoneal carcinosis nor tumour implants at anastomosis sites were observed.

CONCLUSION

This intraperitoneal xenograft tumour model in the pig can be applied in survival studies to check the quality of surgical techniques and its influence on tumour implantation following laparoscopy for cancer.

Is the port site really at risk? Biology, mechanisms and prevention: a critical view

Early case reports of port site tumour implants led to debate regarding the appropriateness of laparoscopic techniques for abdominal malignancies. Review of clinical, animal and cell culture studies addresses the relationships between tumour staging and shed cell behaviour that contributes to the peri-operative spread of tumours. In addition, a porcine model was used to test tumour cell distribution after laparoscopic and open colonic resections. Clinical evidence indicate that wound recurrence rates are 0.60 and 0.85% for open and laparoscopic colon cancer operations, respectively. Tumour staging and operative techniques are the most important factors determining wound implantation. Port site and open wounds are at equal risk of tumour implantation.