The document presents an overview of minimally invasive surgery techniques in oncology, highlighting significant trials and outcomes related to laparoscopic procedures for various cancers. Key findings indicate no substantial differences in overall survival and recurrence rates between laparoscopic and open surgeries, although laparoscopic methods generally offer advantages like reduced blood loss and shorter hospital stays. The data reinforces the ongoing support for minimally invasive approaches across different types of cancer treatments.

1. MINIMALLY INVASIVE
SURGERY IN
ONCOLOGY
DR. D. PRADEEP, MCH SURGICAL
ONCOLOGY
TN GOVT MULTI SUPERSPECIALTY
HOSPITAL, CHENNAI. PRESENTED IN
2019

2. History
 Bozzini and Desormeaux – principle of total
internal reflection in viewing deep seated organs
and genitourinary passages
 Nitze – Cystoscope
 Mikulicz – Gastroscope
 1983 – Lap Appendicectomy by Kurt Semm
 1987 – Lap cholecystectomy by Philip Mouret

3. Core Principles of MIS
 I – VITROS
 Insufflate/create space
 Visualize – anatomical landmarks, tissues
 Identify – specific structures for surgery
 Triangulate
 Retract
 Operate
 Seal/hemostasis

4. Pros and Cons

5. Lap vs Robotic

6. Laparoscopic Surgical Staging in
Endometrial Cancer

7. LACE Trial (Laparoscopic Approach to Cancer Endometrium)
 760 patients

8. Results
 Equivalent DFS at 4.5 years 81.3% TAH vs 81.6%
TLH
 Overall SR at 4.5 years 92.4% TAH vs 92.0% TLH
 Improved Quality of Life Outcome

9. LAP2 Trial – GOG 222
 2616 patients
 Hazard ratio for RFS 1.14
 Limitations – Included high grade and clear cell
variants
 Para aortic lymph nodal staging, peritoneal
cytology done
Lap Arm Open Arm
5 year Recurrence rates 13.68% 11.61%
5 year OS 89.8% 89.8%

11. RESULTS
 Review from 9 RCTs (assessing 4389 women)
 No difference in Overall Survival (HR 1.04)
 No difference in Recurrence Free Survival (HR
1.14)
 Shorter overall hospital stay
 No difference in operative morbidity
 No difference (in fact less blood loss) compared
to open

12. Laparoscopic Radical Hysterectomy
In Early Cancer Cervix

13. Systematic Reviews
 Wang et al – 12 Studies
 No significant differences in 5 year OS and DFS in
both arms
 Operative morbidity, lymph node yield, positive
surgical margins are similar
 Less blood loss, quicker return to normalcy,
shorter hospital stay are advantages
 With compromise in longer operating times

14. LACC Trial (Laparoscopic Approach to Cervical Cancer)
 IA1, IA2 to IB1 cervical cancers
Minimally Invasive
RH
Abdominal RH
No of patients 319 312
DFS at 4.5
years
86% 96.5%
3 year OS 93.8% 99.0%

15. Laparoscopic Rectal Resection
In Rectal Cancers

16. COLOR II Trial
 COlorectal cancer Laparoscopic or Open
Resection
 T3 and T4 rectal lesions excluded
 Any site in rectum included, both post
Neoadjuvant and Upfront surgeries included
@ 3 Years Lap RR Open RR
Patients 699 345
Local Recurrence 5% 5%
DFS 74.8% 70.8%
Overall Survival 86.7% 83.6%
Involved CRM 10% 10%

17. COREAN Trial
 Comparison of Open vs laparoscopic rectal
resection for mid and low REctal cancers After
Neoadjuvant CRT
 2006 to 2009
 Shows long-term oncological safety of
laparoscopic surgery for rectal cancer treated
with NACRT
Laparoscopic
Rectal Resection
Open Rectal
Resection
Patients 170 170
7 year OS 83.2% 77.3% (p=0.48)
7 year DFS 71.6% 64.3% (p=0.20)
7 year Local
Recurrence
3.3% 7.9% (p=0.08)

18. ACOSOG Z6051
 T1 to T3 N0/N+ Low rectal cancers after NACRT
 Study disproves previous standards that
laparoscopy is not considered non inferior to
open surgeries
LAP OPEN
Patients 240 222
4 year DFS 75.2% 73.2%
Local recurrence 2.1% 1.8%
Distant 14.6% 16.7%

19. ALaCaRT Trial
 Australasian Laparoscopic Cancer of Rectum Trial
 T1 to T3 Low rectal cancers to ensure oncological
adequacy of Lap assisted APR vs Open APR
Lap APR Open APR
Patients 238 237
Successful resection 82% 89% p=0.38
Clear CRM 93% 97% p=0.06
Complete TME 87% 92% p=0.06
Clear Distal margin 99% 99% p=0.67

20. CLASSIC Trial
 >15 years follow up
 Long-term results continue to support the use of
laparoscopic surgery for both colonic and rectal
cancer.

21. Meta Analysis
 Martinez Perez et al 2017 (14 RCTs)
 Clinical outcomes: Lesser blood loss, longer
operating time, shorter incision length, lesser
perioperative morbidity in Lap Resection arm
 No difference in distance to distal margins, lymph
nodal yield and distal margin involvement in both
arms
Oncological outcome Lap RR Open RR
Incomplete TME 13.2% 10.4%
Positive CRM 7.9% 6.4%

22. Hybrid Minimally Invasive Esophagectomy
In Esophageal Cancers

23. TIME Trial
 Traditional Invasive vs Minimally invasive
Esophagectomy
 No differences in disease-free and overall 3-year
survival for open and MI esophagectomy and
further support the use of minimally invasive
surgical techniques in the treatment of esophageal
cancer.
MIE OE
Patients 59 56
3 year DFS 42.9% 37.3% (p=0.60)
3 year OS 42.9% 41.2% (p=0.663)

24. MIRO Trial
 69% reduction in major intraoperative and
postoperative morbidity in HMIE arm
 No difference in 30 day mortality (4.9% in both
arms)
HMIE OE
Patients 104 103
Major morbidity 35.9% 64.4% (p=0.0001)
Pulm
complications
17.7% 30.7% (p=0.035)
3 year DFS 57% 48% (p=0.15)
3 year OS 67% 55% (p=0.05)

25. Laparoscopic Radical Nephrectomy
In Renal cell carcinomas

26. Meta Analysis
 Liu et al 2017
 37 articles
 Overall mortality lower in LRN compared to ORN
 Lower cancer specific mortality in LRN compared
to ORN but not statistically significant
 No significant difference in tumor recurrence and
intraoperative complications in both arms
 Postoperative complications seems to be lower in
LRN but not statistically significant
 Longer operative time, shorter hospital stay and
lesser blood loss

27. Thank You