Laparoscopic resection is as effective as open resection for colorectal cancer based on evidence from randomized trials. While laparoscopic surgery provides short term benefits like earlier recovery and less pain, long term oncologic outcomes are equivalent between the two approaches. However, the evidence shows laparoscopic surgery should only be performed by experienced surgeons, as those without extensive laparoscopic experience may not achieve the same results and patient outcomes are worse if conversion from laparoscopic to open is needed.

1. Laparoscopic resections in colorectal
malignancies
What is the evidence ?
Dr Harsh Shah
MS, DNB(GI),MCh(GI)
Kaizen Hospital, Ahmedabad

2. Introduction
• Surgical resection remains the primary treatment modality for
resectable colorectal cancer
• Laparoscopy for colon surgery was originally reported in 1991
by Fowler and White
• Surgical management of colon and rectal cancer has evolved
over the past 2 decades
• Despite an abundance of randomized trial evidence,
laparoscopy remains underused

3. Laparoscopic Colectomy
Advantages
• Cosmetic
• Early recovery
• Less adhesions
• Less hernia & wound
complications
Disadvantages
• Learning curve
• More time taken
• Advanced tumours
• Post-operative sexual
function

4. Issues
• Feasibility
• Short term outcomes
– Early recovery & discharge
– Cosmesis & pain
– Wound related complications
– QOL
• Port site recurrence
• Long term oncological outcome
• Special situations – Obese, geriatric
• Training & assessment

5. Attention Please..
• It should be noted that most of the RCTs included surgeons
with vast laparoscopic experience in high-volume hospitals
• Some of the trials used technical credentialing techniques
before surgeon approval to enroll patients
• Whether the non-credentialed surgeon can achieve the same
results is still debated

6. Colon cancer : short term outcomes
Operative outcomes for laparoscopic versus open resection of
colon cancer in major randomized trials

7. Short-term outcomes for laparoscopic versus open resection of
colon cancer in major randomized trials

8. Cochrane database review - 2005
• 25 randomized trials
• Increased operative time in the laparoscopic group
• Higher blood loss, higher pain scores, longer duration of ileus,
and longer length of stay in open group
• Improved overall morbidity and surgery-specific morbidity in
laparoscopy group

9. Colon cancer : long term outcome
Long-term oncologic outcomes for laparoscopic versus open
resection of colon cancer in major randomized trials
a Five-year outcomes. b Three-year outcomes

10. Long term outcomes
Cochrane database review 2008
• 12RCTs
• comparable survival and local recurrence rates between
laparoscopic and open group
• no differences in the number of reoperations for hernias or
adhesions

11. • Initial high reports – now around 1%
• Incidence close to wound site recurrence in open surgery
• Preventive aspects cannot be ignored
– No handling of tumour
– Isolation of specimen
– Evacuation of pneumoperitoneum through trocar
– Early high ligation of pedicle

12. Rectal cancer: short term outcomes
Operative outcomes for laparoscopic versus open resection of
rectal cancer in major randomized trials and meta-analyses

13. Short-term outcomes for laparoscopic versus open resection of
rectal cancer in major randomized trials and meta-analyses

14. Rectal cancer: long term outcome
Oncologic outcomes for laparoscopic versus open resection of
rectal cancer in major randomized trial
a Five-year outcomes.
Jayne DG, Thorpe HC, Copeland J, et al. Five-year follow-up of the Medical
Research Council CLASICC trial of laparoscopically assisted versus open surgery
for colorectal cancer. Br J Surg 2010;97(11):1638–45

15. Meta-analysis
No difference in oncologic outcomes between open and
laparoscopic TME
• Aziz O, Constantinides V, Tekkis PP, et al. Laparoscopic versus open surgery
for rectal cancer: a meta-analysis. Ann Surg Oncol 2006;13(3):413–24
• Ng SS, Leung KL, Lee JF, et al. Long-term morbidity and oncologic
outcomes of laparoscopic-assisted anterior resection for upper rectal
cancer: ten-year results of a prospective, randomized trial. Dis Colon
Rectum 2009;52(4):558–66

16. Conversion rate
• CLASSIC trial (2005): 34% for laparoscopic rectal cancer
surgery
• More recent studies : 5-8 %
• Factors associated with conversion rate : high body mass
index (BMI), male sex, and locally advanced tumors
• Miyajima N, Fukunaga M, Hasegawa H, et al. Results of a multicenter study of
1,057 cases of rectal cancer treated by laparoscopic surgery. Surg Endosc
2009;23(1):113–8
• Thorpe H, Jayne DG, Guillou PJ, et al. Patient factors influencing conversion from
laparoscopically assisted to open surgery for colorectal cancer. Br J Sur
2008;95(2):199–205

17. • Impact of conversion on survival
• CLASSIC trial (2010)
– Significantly lower OS & DFS at 5 years in patients
requiring conversion

18. • Laparoscopic Rectal Resection for Cancer: Effects of
Conversion on Short-Term Outcome and Survival; Ann Surg
Oncol (2009) 16:1279–1286
• 173 patients
• 26 (15%) required conversion
• No differences in postoperative outcome between CR and
NCR patients
• 5-year disease-free survival was 55.7% in CR group and 79.2%
in NCR group (P = 0.007)

19. Lymph Node Harvest
• 24 RCTs
• 6264 patients
• No difference in the total lymph node count
• Equivalent LN count when colon cancers and rectal cancers
analysed separately
• Wu Z, Zhang S, Aung LH, et al. Lymph node harvested in laparoscopic
versus open colorectal cancer approaches: a meta-analysis. Surg Laparosc
Endosc Percutan Tech 2012;22(1):5–11.

20. COST-EFFECTIVENESS OF
LAPAROSCOPY
• Laparoscopic resection results in savings of $4283
• No difference in quality-adjusted life-years (0.001 more
quality-adjusted life-years than open resection)
• Jensen CC, Prasad LM, Abcarian H. Cost-effectiveness of
laparoscopic vs open resection for colon and rectal cancer. Dis
Colon Rectum 2012;55(10):1017–23

21. Obesity and laparoscopy
• Comprehensive review of 33 studies
• Longer operative times and higher conversion rates (in 5
studies)
• No significant differences in morbidity in most of the studies
(4 studies did show increased morbidity)
• No difference in no. of LNs dissected
• Postoperative recovery of gastrointestinal function : similar
between obese and no-nobese patients.
• Makino T, Shukla PJ, Rubino F, et al. The impact of obesity on perioperative
outcomes after laparoscopic colorectal resection. Ann Surg
2012;255(2):228–36

22. Oncologic outcomes between obese and nonobese patients
• 62 obese and 172 nonobese patients
• No differences in overall or disease-free survival at 2 years
• High conversion rate (44%) for laparoscopic proctectomy in
obese patients
Singh A, Muthukumarasamy G, Pawa N, et al. Laparoscopic colorectal cancer
surgery in obese patients. Colorectal Dis 2011;13(8):878–83

23. Laparoscopy in elderly patient
• Stocchi L, Nelson H, Young-Fadok TM, et al. Safety and advantages of
laparoscopic vs. open colectomy in the elderly: matched-control study. Dis
Colon Rectum 2000;43(3):326–32
lower rates of morbidity, less narcotic use, shorter length
of stay, and shorter postoperative ileus in patients older
than 75 years
Higher postoperative independence in the laparoscopy
group
• Other studies also showed advantages in short-term
outcomes in elderly patients

24. • Altuntas YE, Gezen C, Vural S, et al. Laparoscopy for sigmoid colon
and rectal cancers in septuagenarians: a retrospective, comparative
study. Tech Coloproctol 2012;16(3):213–9.
• A nonrandomized comparison
• 5 year survival in Lap >70 group : similar to that in Lap <
70 group and significantly better than in Open >70 group.

25. Pelvic Nerves
• TME is associated with a risk of erectile and
bladder dysfunction
• CLASSIC study (2005)
– no difference in bladder function between the
laparoscopic and open groups undergoing TME
– a trend toward poor sexual function in the
patients undergoing laparoscopic resection

26. Stamopoulos P, Theodoropoulos GE, Papailiou J, et al.
Prospective evaluation of sexual function after open and
laparoscopic surgery for rectal cancer. Surg Endosc
2009;23(12):2665–74
• 56 patients underwent proctectomy (38 open, 18 laparoscopic)
• Significant reductions in International Index of Erectile
Function (IIEF) scores in the entire group postoperatively
• No significant differences in IIEF scores between the
laparoscopic and open groups at 3 or 6 months
• Baseline IIEF score and the baseline, 3-, and 6-month sexual
desire scores were low in the low anterior resection group than
in the abdominoperineal resection group

27. Learning curve for laparoscopy
• Technically challenging and there is a steep learning curve
• COST and CLASICC trials required a minimum of 20
laparoscopic colectomies before technical credentialing for
trial participation
• Others have described learning curves of 55 for right
colectomy and 62 for left colectomy
• The learning curve is even longer for TME (>120 cases) when
considering oncologic outcomes, such as local recurrence

28. ASCRS & SAGES Guideline
…..Laparoscopic colonic resection produced
similar oncological outcome….should only be
attempted by surgeons experienced with
laparoscopic techniques.

29. Conclusion
Laparoscopy
 Improves short term morbidity
 Equivalent long term outcome
 Experienced laparoscopic surgeon required
 Conversion affects outcome poorly
 Equivalent results in obese & elderly
 May affect sexual function adversely

30. Thank You