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Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
Laparoscopic Resection for Rectal Cancer
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Laparoscopic Resection for Rectal Cancer

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  • Transcript

    • 1.  
    • 2.
      • Laparoscopic colectomy 1 st attempted in early 90’s
      • Slow to gain acceptance unlike rapid take-up of lap cholecystectomy
      • Reasons for this include:
        • Steep learning curve
        • Cost
        • Time
        • Concern re oncological soundness
        • Possible port site metastases
    • 3.
      • Sharp dissection between the parietal and visceral layers of the endopelvic fascia
      • Complete excision of rectum & draining lymphatics with intact visceral envelope
      • Preservation of pelvic autonomics
      • Low local recurrence rates (4% @ 10yrs)
      Heald 1986
    • 4.  
    • 5.
      • Less blood loss
      • Faster recovery
      • Earlier return of gut function
      • Lower morbidity
      • Magnified view allows precise dissection (pelvic autonomics)
    • 6.
      • Reduced pain
      • Improved cosmesis
      • Decreased adhesions
      • Decreased wound infection rate
      • Reduced immune effect of surgery
    • 7.
      • Steep learning curve
      • Longer operating times (+30% to 50%)
      • Cost
        • Instruments / equipment
      • Port-site recurrence?
      • Oncological soundness compared with open TME?
    • 8.
      • Practical and technical limitations
        • Crowding of instruments in the pelvis
        • Plume can obscure vision
        • Retraction of the rectum can be very difficult
        • Division of the rectum can be difficult
        • Identification of tumour site can be difficult
        • Pneumoperitoneum
          • Gas embolism / decreased venous return
    • 9.
      • Purely Laparoscopic
        • Specimen extraction through natural orifice (ie anus)
        • Hand-sewn colo-anal anastomosis
        • No abdominal incision apart from port sites
      • Laparoscopically Assisted
        • Small incision for specimen retrieval
      • Hybrid
        • Incision to allow rectal dissection , vessel ligation or anastomosis to be performed in an open fashion
      • Hand-assisted Laparoscopy
        • Combination of both open and laparoscopic techniques through a hand port
    • 10.
      • Optics / image Processing
      • Energy devices (e.g. harmonic scalpel, bipolar energy)
      • New staplers
      • Wound protectors / retractors
      • Hand assist devices
      • Robotics?
    • 11.
      • Smaller, better optical properties
      • Magnification 15-20X
      • Flexible
    • 12.  
    • 13.
      • Modified lithotomy (adjustable stirrups)
      • Bean bag or soft mouldable mattress to allow maximum tilt
      • 4-5 cannulas (1/quadrant)
      • CO 2 insufflation (12-15mmHg)
      • 30 degree or flexible laparoscope
      • Laparoscope lens cleaner
      • Plume extractor
    • 14.  
    • 15.  
    • 16.  
    • 17.  
    • 18. Incision
    • 19. May expedite the mid and upper abdominal steps
    • 20.
      • Pre-operative assessment
        • Can / should it be done laparoscopically?
      • Lateral to medial dissection
      • Full mobilisation of splenic flexure
      • High vascular division
      • Rectal dissection / division / anastomosis
    • 21.  
    • 22.  
    • 23.  
    • 24.  
    • 25.  
    • 26.  
    • 27.  
    • 28.  
    • 29.  
    • 30.  
    • 31.  
    • 32.
      • Evidence is mainly from comparative non randomised trials
      • Many with small numbers & short follow-up
      • Two randomised trials in the literature looking at lap TME (restorative)
        • (Zhou 2004)
        • MRC CLASICC (Guillou 2005)
      • One RCT on Lap APR
        • (Araujo 2003)
    • 33.
      • Zhou et al (China)
      • Extraperitoneal rectal cancer
      • Lap : open = 82:89
      • No defunctioning ileostomy
      • Short term results only
      • No conversion rate reported
    • 34.
              • Lap Open
      • Mortality (%) 0 0
      • Morbidity (%) 6.1 12.4
      • Leak (%) 1.2 3.4
      • Operation time (min) 120 106
      • Blood loss (ml) 20 106
      • Pain (days) 3.9 4.1
      • First bowel action (days) 4.3 4.5
      • LOS (days) 8.1 13.3 (p=0.001)
    • 35.
      • Guillou et al (UK)
      • Multicentre RCT
      • Colon & rectal cancer
      • All surgeons had performed at least 20 laparoscopic resections
      • 794 patients randomized 2:1 for laparoscopic : open surgery
      • 381 patients with rectal cancer (253:128)
      Lancet 2005 365:1718-26
    • 36.
      • Conversion 34% (overall fall in conversion rate during the trial)
      • Mortality - all patients (colon and rectal)
        • Intention to treat
          • Open 5% Lap 4%
        • Actual treatment
          • Open 5% Lap 1% Conversion 9%
      Lancet 2005 365:1718-26
    • 37.
      • Complications – rectal cancer
        • Intention to treat
          • Open 37% Lap 40%
        • Actual treatment
          • Open 37% Lap 32% Conversion 59% (p=0.002)
    • 38.
      • Open Lap Conv
      • Anaesthetic time* 135 180 180 mins
      • 1 st BM 6 5 6 days
      • Normal diet 7 6 7 days
      • LOS 13 10 13 days
        • *Rectal and colonic resection
    • 39.
      • Cost – intention to treat (mean)
      • Open Lap
      • Theatre £ 1448 £ 1816
      • Hospital £ 3713 £ 3359
      • Others £ 2659 £ 3085
      • Total £ 7820 £ 8260
      Br J Cancer 2006 95:6-12
    • 40.
      • Quality of Life
        • no difference at 2 or 3 months
      • Good quality pathological specimens were received in both groups
        • (nodes and length to vascular tie)
      • Positive CRM rate (anterior resections)
        • Laparoscopic 12% (16/129)
        • Open 6% (4/64)
    • 41.
      • CLASSIC group suggest that laparoscopic anterior resection is not justified as a routinue approach due to concerns over:
        • Increased positive CRM rate
        • High morbidity with conversion
      • Learning curve underestimated at the 20 cases used in the trial
    • 42.
      • Araujo et al (Brazil)
      • 28 patients – laparoscopic vs open APR
      • Results
        • No conversions
        • Operating time faster in laparoscopic group !
          • 228 vs 284 mins (p=0.04)
        • At mean 4yr follow up
          • 0 recurrences in laparoscopic group
          • 2 local recurrences in open group
      Rev Hosp Clin Fac Med Sao Paulo 2003 58:133-40
    • 43.
      • Breukink et al (2006)
      • 48 studies, 4244 patients
      • Poor study methodologies, only 3 RCT’s
      • No strong conclusions possible
    • 44.
      • 5-year disease free survival
        • No apparent difference
      • Local Recurrence
        • Most studies found no significant difference
        • Overall <10% (variable follow up)
        • Higher for APR (0% - 25%)
        • 0% to 6% for sphincter-saving lap TME
        • Comparable to open situation (Heald showed 33% LR after APR)
    • 45.
      • Perioperative mortality
        • No significant difference
      • Morbidity
        • No apparent difference
        • Trend towards lower complications in lap groups
      • Anastomotic leak
        • No difference
    • 46.
      • Blood loss
        • Reduced with lap TME
      • Operative Time
        • Significantly longer with lap TME
      • Conversion Rate
        • Highly variable (0 to 33%)
        • Surgeon experience crucial
      • Surgical margins
        • No difference
    • 47.
      • Lymph node harvest
        • No difference
      • Postoperative recovery
        • Improved with lap TME
      • Quality of life
        • Insufficient data
    • 48.
      • Cost
        • Probably increased for lap TME
        • Poor data
      • Immune response to surgery
        • Appears reduced with lap TME
    • 49.
      • No firm conclusions
      • Laparoscopic TME appears to have short term benefits
      • Long term oncological safety requires further randomized trials
    • 50.
      • Port-site herniae
        • Rare at 0.3%
        • Attention to port site closure
      • Port site metastases
        • First reported 1993
        • Rare at 0.1% overall
        • Comparable to wound recurrence in open surgery
    • 51.
      • Bladder and sexual function
        • Quah (Singapore)
          • 80 patients randomised to open or laparoscopic assisted resection
          • Of sexually active males 46% (7/15) decreased function in laparoscopic group vs 6% (1/15) open
        • CLASICC
          • Erectile dysfunction in 41% of laparoscopic vs 23% open (NS)
      Br J Surg 2002: 89:1551–6 Br J Surg 2005 : 92:1124-32
    • 52.
      • Laparoscopic TME is technically challenging
      • In experienced hands, lap TME can be performed safely and confers short term post-operative benefits in terms of recovery
      • Cost and quality of life data are lacking
      • Long term oncological outcomes are unknown, but should be theoretically no worse if TME principles are followed
      • The 3 and 5-year results from the CLASSIC trial are awaited !

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