archimed.mlsit.ru/img The conventional approach to surgery involves making a cut through the abdominal wall. For many people it is now possible to use video-endoscopic surgery laparoscopy , which may have short term advantages that include less pain, better pulmonary function, shorter time for return of bowel function duration of postoperative ileus , less fatigue, better quality of life and improved convalescence. However, the procedure is complex and for colorectal cancer the oncological long-term results on survival not known. The review authors identified 25 controlled trials in which men and women were randomized to one surgical technique or the other.
Colorectal resection was most often required for colorectal carcinoma. Overall, laparoscopic colon resections showed advantages over conventional surgery. Blood loss was a little less by to 31 ml, mean 72 ml ; pain, which was treated with epidural or patient-controlled on demand analgesia , was less intense; time to return of bowel function was less, by about one day; lung function was improved with reduced postoperative stay in hospital by 1. The operation time was longer with laparoscopic surgery than with conventional surgery by 42 minutes, range 30 to 55 minutes.
Re-operation was not more likely after laparoscopic surgery and general complications in the lungs, heart, urinary tract or deep vein thrombosis DVT were similar with the two surgery techniques. Wound infections were less in laparoscopic patients. Some patients are not suitable for laparoscopy. Under traditional perioperative treatment, lapararoscopic colonic resections show clinically relevant advantages in selected patients. If the long-term oncological results of laparoscopic and conventional resection of colonic carcinoma show equivalent results, the laparoscopic approach should be preferred in patients suitable for this approach to colectomy.
Colorectal resections are common surgical procedures all over the world. Laparoscopic colorectal surgery is technically feasible in a considerable amount of patients under elective conditions. The first case series, mostly involving a small number of cases, focused their interest in confirming the safety of SILS as compared to standard laparoscopy[ 81 , 91 - 93 ].
Later on, comparative non-randomised studies were published[ 85 , 94 - 98 ]. Altogether, these studies showed that SILS was as similar to conventional laparoscopy in terms of early complications such as postoperative bleeding, wound complications, lymph node retrieval and mortality. Regarding other possible benefits of SILS such as reduced postoperative pain or peritoneal adhesions there is no sufficient evidence of the superiority of SILS vs conventional laparoscopy.
It is important to note that the studies published to date have a number of biases limiting the value of their conclusions. Moreover, patients undergoing SILS surgical procedures are operated by select groups of surgeons with special interest and skills in laparoscopic surgery; this could be a limitation in order to reproduce the same results in other institutions.
In , two randomised studies were published comparing SILS with conventional laparoscopy. In one the study that included only 32 colon cancer patients, Huscher et al[ 99 ], concluded that SILS for colon cancer was feasible and safe as conventional laparoscopy, by they found no differences of SILS in terms of postoperative morbidity, first time of oral intake and length of hospital stay. By contrast, in a randomised study including 25 patients per group, Poon et al[ ], showed that SILS was associated with lesser pain and shorter hospital stay.
In the same year, the first meta-analysis including 14 studies[ ], only one randomised, reported the same conclusions; there were no significant differences between two approaches, so the authors considered that SILS was just an alternative for colorectal cancer surgery.
The meta-analysis published by Maggiori et al[ 28 ] is important because more than patients operated on by SILS were included. According to the results of this systematic review and meta-analysis suggest that single-incision laparoscopic colorectal surgery is feasible and safe. Another systematic review published in [ ] confirmed the lack of superiority of SILS over conventional laparoscopy. Results of this review, however, should be interpreted taking into account some limitations including, selection bias in SILS patients and surgical expertise as well as heterogeneity among studies and differences in the primary endpoints.
One year later, in another meta-analysis with more than patients per group Yang et al[ ] that patients undergoing SILS had shorter length of stay, shorter incision length, less estimated blood loss and more lymph nodes harvested, with the same number of postoperative complications and the same operative time. In the conclusions of this study the authors also admitted that SILS was performed only by experienced surgeons. Similar conclusions have been reached in more recent meta-analysis[ ]. Two special topics merit to be mentioned apart.
One of the supposed advantages of SILS is cosmesis but, this topic has been refuted by some authors[ 95 , 98 , ]. Although many studies have demonstrated, obviously, that SILS is associated with a shorter incision[ 28 , , ], the majority of authors agree that there is a lack of consensus on how to evaluate the cosmetic results and that cosmetic evaluation should only be performed after completion of the healing process and by an independent clinician.
Another special issue of SILS is cost.
In the early years, SILS was more expensive than conventional laparoscopy due to development of new trocars and new instruments. This fact has been confirmed by some authors[ ] but with the increased in development of instruments and the competition between providers, both techniques have equalized in costs; today the cost of SILS port is just a little higher than the four conventional laparoscopy ports[ 94 , 96 ].
Based on the available evidence it cannot be concluded that SILS is better than conventional laparoscopy. In our opinion, this approach should be reserved to selected patients, with low BMI, small size tumours and preferably localised in right colon and selected surgeons. Data regarding long-term oncological results for malignant diseases cannot be presented given the lack of long-term follow-up studies. One step beyond minimally invasive surgery is robotic surgery. Robotics were applied to surgery in s in the military setting; the first robot entering in an operating room was designed in and, since then, multiple tele-manipulators have been proven until the introduction of the da Vinci robotic surgical system Intuitive Surgical, Inc, Sunnyvale, Calif that has revolutionised this field.
This new approach provides three-dimensional image, diminishes surgeon tremor, allows dexterity and ambidextrous capability, is associated with shorter learning curve, and provides human wrist-like motion for the instruments[ ]. All these advantages are particularly useful in operations performed in small fields in which high precision is crucial[ ].
However, despite the growing number of published articles on this topic there is lack of evidence about long-term oncological safety or its clinical benefits over conventional laparoscopy. Moreover this technique is expensive, which is a major drawback to the widespread adoption of robotic surgery in the present time of budget constraints[ ]. Evidence of the usefulness of robotic surgery was firstly reported in prostate, gynaecological and cardiac surgery but no was until when Weber et al[ ] published the first two cases of robotic colectomies.
Since then, there has been a rapid growing of evidence about colon and, specially, rectal cancer. Araujo et al[ ] found only two publications between and and more than 20 manuscripts published between and regarding this topic.
It is important to note that the evidence available until today about robotic surgery shows a great difference between colon and rectal surgery. In the development of this new approach different difficulties and challenges have been described and this is why deserved to be considered separately. Robotic colon surgery differs from robotic rectal surgery because one of the most important disadvantages of this technique is limited intracorporeal possibility of motion. Surgery of the colon requires access to more than one quadrant of the abdomen. This fact needs repositioning of the robotic arms, increasing the operative time.
The first case series[ , - ] reported the benefit of the new approach in specific steps of the surgical procedure, such as take down of the splenic flexure or hand sewn anastomosis, but stressed major drawbacks regarding higher cost and longer operative times. Another steps of laparoscopic colectomy where robotic colorectal surgery has shown superiority compared with conventional laparoscopy is are accurate lymphadenectomy around major vessels and the ability to perform intracorporeal anastomosis[ ].
In a randomised controlled trial with right-sided colonic cancer patients undergoing right hemicolectomy the duration of surgery was longer and the overall cost greater in the robotic group compared with the conventional laparoscopic group[ ]. In summary, robotic colorectal surgery is a safe and feasible technique but is associated with higher costs and longer operative times.
The long-term results in patients with colon cancer are still to be determined. Special mention should be made of the use of robotics in patients with rectal cancer, where robotic surgery permits the access to a narrow pelvic cavity with an excellent surgical view. As previously mentioned, the need to perform a total mesorectal excision in a deep and narrow pelvis increases the technical complexity of this procedure and the risk of oncological compromise[ ].
In this regard, robotic surgery allows for a very precise dissection. With robotics total mesorectal excision and preservation of urinary and sexual functions can be achieved with more security[ ]. Even more, some studies suggest that robotic surgery may attenuate the learning curve for laparoscopic rectal resection[ ]. The first evidence described for treatment of rectal cancer with total mesorectal excision was in [ , ]; two studies with a small number of patients confirmed that robotic surgery was as safe and feasible technique as conventional laparoscopy.
During the last years, a large number of studies have been published including clinical series[ , ], comparative studies[ , ] and one randomised controlled trial[ ]. The results of all of them agree that robotic surgery is safe and can be reproduced, with a higher cost and longer operative time; similarly, these studies pint out the absence of evidences about oncological outcomes.
In a recent review of Araujo et al[ ], a total of patients with rectal cancer that underwent minimally invasive robotic surgery in 32 studies were evaluated. In this study the authors found no differences between robotic and laparoscopic surgery regarding morbidity and anastomotic complications. Robotic surgery was better in short-term oncological results, larger number of lymph nodes harvested and greater distance of resection margin. However, the authors insist in the fact that this new approach is associated with increased costs and longer operative times.
Other meta-analyses have obtained similar results[ - ]. More recently, Park et al[ ] have published the first study of long-term oncologic outcomes of rectal cancer patients undergoing robotic surgery compared with conventional laparoscopy. In this prospective study, no significant differences were found in the 5-year overall, disease-free survival and local recurrence rates between robotic and laparoscopic surgical procedures and, once again, robotic surgery was associated with higher costs.
Other systematic reviews and meta-analyses have investigated the impact of robotic surgery including together patients undergoing colon and rectal surgery[ , - ] and have confirmed the results of previous studies: robotic colorectal surgery is a safe and feasible option and show comparable short-term outcomes compared to conventional laparoscopic surgery.
In summary, there is no evidence supporting the superiority of robotic surgery over standard laparoscopy in procedures for colon or rectal cancer. Further studies are required to evaluate oncologic safety and functional results. Moreover, the aforementioned drawbacks, longer operative time and higher costs, are factors associated with a slow implementation of this technology. Natural orifice transluminal endoscopic surgery NOTES appeared as a further step of the laparoscopic approach with a preservation of the abdominal wall integrity.
It proposes the access to the peritoneal cavity with flexible endoscopic or rigid laparoscopic instruments using natural openings such as the mouth transgastric , the urethra transvesical , the vagina transvaginal and the anus transcolonic [ ]. In the field of colorectal surgery, transrectal NOTES has been accepted as a hybrid procedure assisted by laparoscopy, and also as a pure access to resect a rectal and also a colon specimen.
In , Whiteford et al[ ] published the first successful pure transanal NOTES sigmoidectomy using transanal endoscopic microsurgery TEM instrumentation in a cadaveric model with success. Later on, in , Velhote et al[ ] published a pure NOTES in a patient in which they performed a transanal endorectal pull-trough sigmoidectomy. Although there are few case reports describing the results of pure colon resection NOTES, nowadays, the hybrid technique using laparoscopic trocars and transvaginal[ ] or transanal approach[ ] to excise the specimen seems to be more accepted among colorectal surgeons.
In the last years, different colorectal surgery groups have used NOTES approach for total mesorectal excision TME through the anus assisted by laparoscopy to treat low and medium rectal cancer. The purpose is to give a safe and feasible alternative to the open and laparoscopic TME. Since its introduction in , TEM[ ] has become an effective and well-established surgical approach to excise benign rectal adenomas and early stage rectal cancer.
This minimally invasive technique offers the advantage of better controlled full-thickness rectal wall excision in a narrow operative field compared to endoscopic submucosal dissection[ 63 ] or transanal local excision[ ]. In addition, TEM approach is a feasible alternative to radical excision of the rectum with lower morbidity and mortality[ ] in low risk T1 adenocarcinoma[ ].
Furthermore, TEM has a role as a palliative technique in patients who refuse radical excision or are medically unfit for radical resection. This new technique is characterised by a different platform. They proposed to use a single port laparoscopic device transanally to excise rectal tumours instead of the rigid and longer rectoscope of the TEM.
These authors showed that TAMIS is a feasible and safe alternative to TEM, with technical advantages, quicker settling of the operative field and less expensive.
Several important new studies1–3 have demonstrated the benefits and safety of laparoscopic colorectal surgery, making it now the preferred approach in the. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits.
Since then, several case reports and also some small clinical series[ - ] of TME for rectal cancer using transanal NOTES approach with laparoscopic assistance have been published. Emhoff et al[ ] have recently reviewed the first published series and reported favourable short-term outcomes in selected patients. They demonstrate that endoscopic transanal proctectomy is a safe and reproducible procedure and does not negatively impact the oncological dissection or functional outcomes[ ]. Recently, Fernandez et al[ ] have published the first prospective cohort study of patients treated by transanal NOTES assisted by laparoscopy compared to a retrospective historical cohort treated by laparoscopic TME.
This study confirms that transanal TME is a feasible and safe technique associated with a shorter surgical time and a lower early readmission rate compared to laparoscopic TME[ ]. However, randomised controlled trials are neccesary to evaluate the short-term outcomes and long-term functional and oncological results. The proctotomy used to remove the specimen would be incorporated in the final colorectal or coloanal anastomosis.
Moreover, this is not the only advantage; experienced colorectal surgeons with this approach point out to a better visualisation of the tumour distal edge so that a clear negative distal resection margin could be done. It seems particularly indicated in patients with unfavourable characteristics such as male gender obesity, narrow pelvis and bulky tumours[ - ]. It will play an important role in minimally invasive colorectal surgery allowing to perform the transanal TME after the abdominal approach.
This review of recent controversies and latest innovations in the use of laparoscopic surgery for colon and rectal diseases, allows us to know more about this approach and its implementation. The authors thank Marta Pulido, MD, for editing the manuscript. Conflict-of-interest statement: No potential conflicts of interest; no financial support; the authors have no conflicts of interest to be declared. Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers.
Peer-review started: May 20, First decision: September 9, Article in press: December 14, National Center for Biotechnology Information , U. Journal List World J Gastroenterol v. World J Gastroenterol. Published online Jan Author information Article notes Copyright and License information Disclaimer.
Author contributions: Pascual M and Salvans S performed search, reviewed articles and wrote the manuscript; Pera M reviewed articles and wrote the paper. Published by Baishideng Publishing Group Inc. All rights reserved. This article has been cited by other articles in PMC. Abstract The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. Keywords: Laparoscopy, Inflammatory bowel disease, Surgical innovations, Colorectal cancer, Single incision laparoscopic surgery, Robotic surgery, Natural orifice transluminal endoscopic surgery.
Laparoscopy and colon cancer The impact of laparoscopy on long-term oncological outcome was a subject of controversy for many years, especially because of port-site metastasis and concerns regarding lower number of lymph nodes retrieved[ 11 ]. Laparoscopy and inflammatory bowel disease The development of laparoscopic procedures for benign conditions has met with technical difficulties, even higher than in patients with cancer, particularly when treating patients with inflammatory disorders such as diverticular disease[ 27 ] or inflammatory disease[ 28 ], which frequently involves adjacent structures.
CURRENT STATUS Although the use of laparoscopic colorectal surgery has been increasing in recent years, the percentage of patients who undergo surgery using minimally invasive techniques is still limited and there are also significant differences among centres[ 49 , 50 ]. The authors concluded that there is a trend of increasing use of laparoscopy in colorectal surgery, across hospital in the United States in the recent years[ 53 ] with acceptable conversion rates The use of laparoscopy in colorectal surgery should be calculated in relation to the number of patients who are candidates for minimally invasive surgery.
Table 1 Summary of key studies comparing the use of laparoscopy and open surgery in patients with cancer. Open in a separate window. RCT: Randomised controlled trial.
Table 2 Intracorporeal vs extracorporeal anastomosis in right laparoscopic colectomy. Single incision laparoscopic surgery After the great development of laparoscopic surgery for the treatment of colorectal diseases over the two past decades, a new procedure emerged in order to improve even more its results. Robotic laparoscopic colorectal surgery One step beyond minimally invasive surgery is robotic surgery. Natural orifice transluminal endoscopic surgery Natural orifice transluminal endoscopic surgery NOTES appeared as a further step of the laparoscopic approach with a preservation of the abdominal wall integrity.
Footnotes Conflict-of-interest statement: No potential conflicts of interest; no financial support; the authors have no conflicts of interest to be declared. References 1. Surgical innovation. Br J Surg. Minimally invasive colon resection laparoscopic colectomy Surg Laparosc Endosc. Laparoscopically assisted vs open colectomy for colon cancer: a meta-analysis.
Arch Surg. Hand-assisted laparoscopic surgery vs standard laparoscopic surgery for colorectal disease: a prospective randomized trial. Surg Endosc. Laparoscopic resection of rectosigmoid carcinoma: prospective randomised trial. Lancet Oncol. Acute phase response in laparoscopic and open colectomy in colon cancer: randomized study. Dis Colon Rectum. Interleukin-6 response to laparoscopic and open colectomy. Randomized clinical trial comparing inflammatory and angiogenic response after open versus laparoscopic curative resection for colonic cancer.
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Impact of gas less laparoscopy and laparotomy on peritoneal tumor growth and abdominal wall metastases.