One of the most common cancers in the world
US: 4th most common cancer
(after lung, prostate, and breast cancers)
2nd most common cause of cancer death
(after lung cancer)
2007: 130,000 new cases of CRC
56,500 deaths caused by CRC
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
Dr Pradeep Jain Fortis Hospital - Current Applications of Lap in GI SurgeryDr Pradeep Jain Reviews
Dr Pradeep Jain Fortis Hospital - Current Applications of Lap in GI Surgery. Dr. Pradeep Jain Fortis Hospital has over 20 years of experience in the Laparoscopic GI and GI Oncology Surgery.
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
Dr Pradeep Jain Fortis Hospital - Current Applications of Lap in GI SurgeryDr Pradeep Jain Reviews
Dr Pradeep Jain Fortis Hospital - Current Applications of Lap in GI Surgery. Dr. Pradeep Jain Fortis Hospital has over 20 years of experience in the Laparoscopic GI and GI Oncology Surgery.
Caudate lobe resection by Dr Harsh Shah(www.gastroclinix.com)Dr Harsh Shah
The ability to resect the caudate lobe in isolation is considered the ultimate expertise in liver resection. This presentation deals with all the feasible approaches to caudate lobe.
Surgery of Rectal Cancer : Potentials and Limitations - Dimitris P. KorkolisDimitris P. Korkolis
EPIDEMOLOGY
2015 Estimates
New cases: 96,830 (colon); 40,000 (rectal)
Deaths: 50,310 (colon and rectal combined)
Death rate over last 20 years declining
Screening and improvements in treatment
Caudate lobe resection by Dr Harsh Shah(www.gastroclinix.com)Dr Harsh Shah
The ability to resect the caudate lobe in isolation is considered the ultimate expertise in liver resection. This presentation deals with all the feasible approaches to caudate lobe.
Surgery of Rectal Cancer : Potentials and Limitations - Dimitris P. KorkolisDimitris P. Korkolis
EPIDEMOLOGY
2015 Estimates
New cases: 96,830 (colon); 40,000 (rectal)
Deaths: 50,310 (colon and rectal combined)
Death rate over last 20 years declining
Screening and improvements in treatment
Information about Low Anterior Resection by Dr Dhaval Mangukiya.
Details of GOAL of LAR, Margins, Reconstructions, Anal Anastomosis, End to Side Colorectal Anastomosis, Stapler Vs Hand Sewn, Intersphincteric Resection, Colonic J pouch Anastomosis etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Laparoscopic Natural Orifice Specimen Extraction (NOSE) Total Colectomy with ...semualkaira
The benefit of laparoscopic surgery in terms of
reduced pain and fewer cosmetic problems is not always obvious,
and surgeons continue to seek the best ways to limit incision trauma and improve outcomes in laparoscopic colorectal surgery
Rectum cancer surgery. Standards of Surgical practice for resectable rectal c...Tariq Khan
Rectum cancer treatment is changing day by day. The current standards of surgical treatment is discussed here. We practice in Shaheed Suhrawardy Medical College, Dhaka and BRB Hospitals Ltd, Dhaka
Abdominal Trauma
Blunt Abdominal Trauma
INDICATIONS FOR LAPAROTOMY
ROLE OF DIAGNOSTIC LAPAROSCOPY
FAST EXAM
HEPATIC AND SPLENIC INJURIES
RETROPERITONEAL HEMORRHAGE
DUODENAL AND PANCREATIC INJURY
DIAPHRAGMATIC RUPTURE
SMALL BOWEL INJURY
INJURY TO COLON AND RECTUM
Penetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Gunshot Wounds
DIAGNOSTIC LAPAROSCOPY
Abdominal Trauma
Blunt Abdominal Trauma
INDICATIONS FOR LAPAROTOMY
ROLE OF DIAGNOSTIC LAPAROSCOPY
FAST EXAM
HEPATIC AND SPLENIC INJURIES
RETROPERITONEAL HEMORRHAGE
DUODENAL AND PANCREATIC INJURY
DIAPHRAGMATIC RUPTURE
SMALL BOWEL INJURY
INJURY TO COLON AND RECTUM
Penetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Gunshot Wounds
DIAGNOSTIC LAPAROSCOPY
Laparoscopic Low Anterior Resection for Cancer : “Pursued or just Permitted?”...Dimitris P. Korkolis
Potential Advantages of Lap TME
- Less blood loss
- Faster recovery
- Earlier return of gut function
- Lower morbidity and mortality
- Magnified view allows precise dissection (pelvic autonomics)
- Earlier hospital discharge
Χαμηλή Πρόσθια Εκτομή : «Η Λαπαροσκοπική Προσπέλαση Πλεονεκτεί για τον Ασθενή...Dimitris P. Korkolis
Potential Advantages of Lap TME
- Less blood loss
- Faster recovery
- Earlier return of gut function
- Lower morbidity and mortality
- Magnified view allows precise dissection (pelvic autonomics)
- Earlier hospital discharge
H Χειρουργική Αντιμετώπιση του Καρκίνου στον Οισοφάγο - Δημήτρης Π. ΚορκολήςDimitris P. Korkolis
- 5% των καρκίνων του πεπτικού συστήματος
- Άνδρες > 60 ετών Άνδρες : Γυναίκες = 3:1
- Αδενοκαρκίνωμα (40%)!!!!!:
- ΓΟΠ – Barrett’s - Παχυσαρκία
- Πλακώδες Καρκίνωμα (60%):
- Κάπνισμα – Αλκοόλ
- 85% στο μέσο ή κάτω 3μόριο του οισοφάγου
- Ελλάς: 3 περιστατικά / 100000 κάτοικοι Χαμηλότερο ποσοστό στην EU
- 5% των ασθενών με εντοπισμένη νόσο κατά τη διάγνωση
- <50%>< 25%
- 5ετής επιβίωση ≤ 20% μετά από χειρουργική αντιμετώπιση
Surgical Anatomy of the Liver : Ηepatectomies - Dimitris P. KorkolisDimitris P. Korkolis
- The liver is the largest gland in the body and has a wide variety of functions
- Weight: 1/50 of body weight in adult & 1/20 of body weight in infant
- It is exocrine(bile) & endocrine organ(Albumin , prothrombin & fibrinogen)
Function of the liver :
- Secretion of bile & bile salt
- Metabolism of carbohydrate, fat and protein
- Formation of heparin & anticoagulant substances
- Detoxication
- Storage of glycogen and vitamins
- Activation of vita .D
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
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18. Rectal Ca Radical excision - Left colon
mobilization
• Splenic flexure mobilization
• Sigmoid colon resected
– Quality of circulation is poor
– Functional outcomes as neo-rectum poor
• High ligation of IMA
– Allows mobilization of descending colon
• Ligation of main trunk of left colic
19.
20.
21.
22.
23. Radical excision-Total Mesorectal
Excision(TME)
• Introduced by RJ Heald in 1979
• Use of sharp dissection under vision to mobilize the rectum
rather than the conventional blunt finger dissection
• First series of 112 pts: 5yr LR 2.9% and survival 87.5%
• Local recurrence:
– Conventional surgery: 11.7 - 37.4%
– TME surgery: 1.6 - 17.8%
• Higher leaks rates reported possibly due to:
– Devascularisation of distal rectal stump
– Lower anastomosis
– Other factors: stomas, drains
24. TME - Technique
• Peritoneal incision around rectum
• Rectosigmoid reflected ant and posterior avascular plane
developed using sharp scissor or diathermy dissection under
vision
• Blobbed lipoma should be demonstrated
• Posterior dissection first, then lateral and finally anterior
dissection
• Do not ‘finger hook’ or clamp the lateral ‘ligaments’
• Partial TME to a distance 5cm distal to tumour
• Anterior dissection incorporates Denonvilliars fascia?
28. TME - Nerve injury
Preaortic sympathetics during high ligation
Sympathetics at the pelvic brim during rectal mobilization
Parasymp(nervi erigentes) and sympathetics during
posterolateral dissection
No clear lateral ligaments
Do not hook or clamp these tissues, avoid excessive traction
Higher rates exp by Japanese with extended lateral LN dissection
Anterior lateral dissection off the prostatic capsule
The most likely area of damage, reflected by higher rates of sexual
dysfunction in APR(14-51%) vs AR(9-29%)
The role of denonvilliars fascia
29. TME - Distal resection margin
• Not clear in the literature
• 5cm preop will expand to 7-8cm on
rectal mobilization
• This will shrink to 2-3cm with specimen
removal and formalin fixation
• Rare for tumour to spread beyond 1.5cm
• Rare reports of poorly diff tumours
having spread 4.5cm distally
• Recommend: 5cm ideally however 2cm
is adequate
30. Reconstruction of Neorectum
• Hand sewn sutured anastomosis
– 1982: Parks and Percy performed the coloanal sutured anastomosis
– ‘Pulled through’ colo-anal anastomosis (Turnbull & Cuthbertson)
• Stapled anastomosis
– Circular stapled technique
– Double stapler technique
• For low and colo-anal anastomosis
31. Reconstruction of Neorectum
Straight end to end
Low AR or Coloanal end-to-end anastomosis cause tenesmus, urgency and
incontinence (Anterior resection syndrome)
Colonic J Pouch
Increases volume of neorectum
5 vs 10cm pouches have smaller reservoirs but better evacuation
(Hida et al., Ds Colon Rectum 1996)
Size is critical to functional outcome, recommend 5-8 cm
Sigmoid colon should not be used
Better short term functional results and possible lower anastomotic leaks
compared to end-to-end anastomosis
Transverse Coloplasty
New technique introduced in 1999 (Z’graggen et al., Dig Surgery 1999)
Better in narrow pelvis and limited length of colon
Long incision closed transversely
Randomized trial underway comparing to J-pouch
34. Abdominoperineal Resection
• Described by Sir Ernest Miles 1908
• 1-2 surgeons
• TME rectal dissection
• Anus sutured closed
• Wide perineal dissection, starting from posterior to lateral then anterior
• Anterior dissection can proceed cranio-caudal or vice versa
• SB exclusion - omentum or absorbable mesh
• Drain the pelvic space
• Reduced rates of APR
– Coloanal anastomosis
– Acceptance of smaller margins
– Downsizing by chemoradiotherapy
45. History
• 1982 Semm performed first
Laparoscopic Appendicectomy
• 1987 Mouret performed first
Laparoscopic Cholecystectomy
• 1992 First UK Laparoscopic Training
centres established
47. Rewards of Minimally Invasive
Techniques
Operative Time
Cost
Benefits of
New
Techniques
Risk/Effects
Of Anesthesia,
Trauma, Etc.
48. Background
Laparoscopic colectomy 1st 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 for oncological soundness
› Possible port site metastases
49. Preoperative Considerations
• Site (Right and sigmoid easier)
• Tumor size/invasion
• Obesity
• Previous surgery
• Almost always get a pre-op CT (cancer)
• Must talk with patient about need for
conversion to open
• Must be able to find tumor/polyp (tattoo!,
0.5cc India ink in 3-4 sites)
51. Preoperative Considerations
Continued
• Can also locate with BE
• Having to do intraoperative colonoscopy is a
flail
– CO2 colonoscopy may be better
• Bowel Preparation
– Utility is debatable, but with laparoscopy it makes
bowel easier to handle
52. Conversion to Open
• 10-25%
– Obesity
– Prior surgery
– Acute inflammation
• Fistula – 50% conversion
– Tumor bulk
• Not a failure
• Early conversion preserves good outcomes
(Wolff, 2007)
53. What difference does it make?
Laparoscopic Colectomy
•It helps you get a job
•Patients like it (thanks to the internet)
•Referring doctors like it
•But what difference does it really make
54. Outcomes
• Ileus – average 1-2 days shorter with
laparoscopy
• Less need for narcotics
• Quicker return of pulmonary function
• Length of stay ~1 day less
• May be influenced by biased expectations
– Who cares?
(Wolff, 2007)
55. Outcomes – Page 2
• Return to work and quality of life
– No statistical change
– Anecdotally improved
• Cost
– Equipment costs and OR time are greater
– May be balanced or outpaced by shorter hospital
stay
• Time – Average 30-60 minutes longer
(Wolff, 2007)
56. Port-Site Metastasis
• Initial concern greatly slowed development of
laparoscopic colectomy
• Not born out in major trials
57. Port site recurrence
• 1-21% incidence
• 3 of 14 patients
• ASCRS registry 1.1%
• Incidence in open wounds = 1%
• Not a problem
62. COST Trial
Clinical Outcomes of Surgical Therapy Study Group
• 872 patients with colonic adenocarcinoma
• Recurrence
– 16% lap
– 18% open
• Survival
– 86% lap
– 85% open
• Post-operative stay
– 5 days lap
– 6 days open
(COST Study, 2004)
63. COST Trial
Clinical Outcomes of Surgical Therapy Study Group
• 5 year data published October 2007
• Disease-free 5 year survival
– 68.4% Open
– 69.2% Laparoscopic
• Overall survival
– 74.6% Open
– 76.4% Laparoscopic
• Recurrence
– 21.8% Open
– 19.4% Laparoscopic
(COST Study, 2007)
64. COLOR Trial
COlon cancer Laparoscopic or Open Resection
• 1248 patients
• 17% conversion to open
• BMI>30 excluded (because started in 1997)
• Pathologic criteria no different
• Time to GI recovery, 1st BM, hospital stay all
one day less
• Complications were equivalent
(COLOR Trial, 2005)
65. MRC CLASSICC
Medical Research Council trial of
Conventional versus Laparoscopic-ASsisted
Surgery In Colorectal Cancer
• 794 patients
• Pathologic specimens, complications were
similar
• Time to 1st BM 1 day shorter
• Time to diet and discharge similar between
groups
(Guillou et al, 2005)
68. Long – Term Results in Colon Cancer
Lai JH, et al. Br Med Bull 2012
69. Hand Assisted Laparoscopy vs.
“Pure” Laparoscopy
• May reduce learning curve
• May be used “up front” or as a “pseudo-conversion”
• Need to make an incision large enough for the
specimen anyway
• Outcomes similar to laparoscopy, with operative
times usually shorter
76. Hand-assist vs. Laparoscopy
Marcello et al
• 95 patients - left or total colectomy
• Randomized to HA vs LAP
• Left colectomy
– 175 minutes HA, 208 LAP (p=0.021)
– Flatus 2.5 vs 3 days (p=0.64)
– Length of stay 5 vs 4 days (p=0.55)
• Total colectomy
– 127 vs 184 minutes (p=0.015)
(Marcello et al, 2008)
77. In a comparison of “pure”
laparoscopy and HALS, what does
no significant difference mean?
It means that if you can do it more easily
with one hand in, why not do it?
118. TME - Gold Standard
• 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
119. Potential Advantages of Lap TME
• Less blood loss
• Faster recovery
• Earlier return of gut function
• Lower morbidity
• Magnified view allows precise dissection
(pelvic autonomics)
120. Potential Advantages of Lap TME
• Reduced pain
• Improved cosmesis
• Decreased adhesions
• Decreased wound infection rate
• Reduced immune effect of surgery
121. Potential Disadvantages
• Steep learning curve
• Longer operating times (+30% to 50%)
• Cost
– Instruments / equipment
• Port-site recurrence?
• Oncological soundness compared with open
TME?
122. Potential Disadvantages
• 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
123. Techniques
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
124. New Technologies
• Optics / image Processing
• Energy devices (e.g. harmonic scalpel, bipolar
energy)
• New staplers
• Wound protectors / retractors
• Hand assist devices
• Robotics?
134. Technique:
General principles
• Pre-operative assessment
– Can / should it be done laparoscopically?
• Medial to Lateral dissection
• High vascular division
• Full mobilization of splenic flexure
• Rectal dissection / division / anastomosis
146. Should We Go There?
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)
147. Laparoscopy: Rectal Cancer
Open Laparoscopic
Patients 89 82
Mean age (years) 45 44
Dukes’ Stage
A
B
C
D
6
8
68
7
5
10
63
4
Prospective, Randomized, Controlled – Short-term outcome
of TME with anal sphincter preservation (ASP)
Zhou, Surg Endosc 2004
148. Laparoscopy: Rectal Cancer
Results of Surgery
Open
(n=89)
Laparoscopic
(n=82)
Distance of Tumor from Dentate (cm)
1.5-4cm
4.1-7cm
56
33
48
34
Distal Margin 1.5-3.5 1.5-4.0
Sphincter preservation 100% 100%
Anastomotic height
Low anterior (>2cm from dentate)
Ultralow anterior (<2cm from dentate)
Coloanal (at or below dentate)
35
27
27
30
27
25
Diverting ileostomy 0 0
Zhou, Surg Endosc 2004
149. Laparoscopy: Rectal Cancer
Open Laparoscopic P
value
Operative time (min) 106 120 NS
Blood loss (ml) 92 20 0.02
Parenteral analgesics (days) 4.1 3.9 NS
Solid intake (days) 4.5 4.3 NS
Hospitalization (days) 13.3 8.1 0.001
Morbidity
Anastomotic leak
12.4%
3
6.1%
1
0.016
Mortality 0 0 NS
Follow-up 1-16 months
Port site mets NA 2
Pelvic recurrence 3 0
Zhou, Surg Endosc 2004
150. MRC CLASICC:
Short term end-points of conventional vs laparoscopic-
assisted surgery in patients with rectal cancer
• 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
151. MRC CLASSIC:
Results
• 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
152. MRC CLASSIC:
Results
• Complications – rectal cancer
– Intention to treat
• Open 37% Lap 40%
– Actual treatment
• Open 37% Lap 32% Conversion 59% (p=0.002)
153. MRC CLASSIC:
Results
Open Lap Conv
• Anaesthetic time* 135 180 180 mins
• 1st BM 6 5 6 days
• Normal diet 7 6 7 days
• LOS 13 10 13 days
*Rectal and colonic resection
154. MRC CLASSIC:
Results
• 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
155. MRC CLASSIC:
Results
• 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)
156. MRC CLASSIC:
Conclusions
• CLASSIC group suggest that laparoscopic anterior resection is
not justified as a routine approach due to concerns over:
– Increased positive CRM rate
– High morbidity with conversion
• Learning curve underestimated at the 20 cases used in the trial
157. Cochrane Review:
Lap vs open TME for rectal cancer
• Breukink et al (2006)
• 48 studies, 4244 patients
• Poor study methodologies, only 3 RCT’s
• No strong conclusions possible
158. Cochrane Review:
Results
• 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)
159. Cochrane Review:
Results
• Perioperative mortality
– No significant difference
• Morbidity
– No apparent difference
– Trend towards lower complications in lap groups
• Anastomotic leak
– No difference
160. Cochrane Review:
Results
• 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
161. Cochrane Review:
Results
• Lymph node harvest
– No difference
• Postoperative recovery
– Improved with lap TME
• Quality of life
– Insufficient data
162. Cochrane Review:
Results
• Cost
– Probably increased for lap TME
– Poor data
• Immune response to surgery
– Appears reduced with lap TME
163. Cochrane Review:
Conclusions
• No firm conclusions
• Laparoscopic TME appears to have short term
benefits
• Long term oncological safety requires further
randomized trials
164. Specific Issues
• Port-site hernia
– 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
165. Specific Issues
• 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
166. Laparoscopy: Total Mesorectal Excision
(TME) case control study
Breukink, Int J Colorectal Dis 2005
VARIABLE/GROUP LAPAROSCOPIC OPEN P value
OPERATIVE TIME(min) 200 180 0.06
BLOOD LOSS(ml) 250 1000 <0.001
>1000 ml FLUID INTAKE 3 6 0.002
SOLID DIET (days) 4 7 0.046
HOSPITALIZATION
(days)
12 19 0.007
MORBIDITY 37% 51% N/A
ANASTOMOTIC LEAK
(n)
2 2 N/A
MORTALITY(n) 0 1 N/A
167. Laparoscopy: Total Mesorectal Excision
(TME) case control study
VARIABLE/GROUP LAPAROSCOPIC OPEN
CIRCUMFERENTIAL
MARGIN(mm)
3 (2-31) 5 (2-31)
DISTAL MARGIN mm 35 (10-100) 10 (1-30)
NUMBER OF NODES 8 (1-25) 8 (2-20)
FOLLOW UP (months) 14 (2-31) 19 (2-31)
LOCAL RECURRENCE 0 0
DISTANT METASTASIS 5 5
Breukink, Int J Colorectal Dis 2005
168. N Conversion
OR
Time
(mins)
Anastomotic
Technique
Goh, 97 OLAR
LLAR
20
20
-
0%
73
90
Partial TME with double
staple
Leung, 97 OLAR
LLAR
50
50
-
16%
150
196
Partial TME with double
staple
Schwander, 99 OLA/pr
LLA/pr
32
32
-
NS
209
281
LAR 19 Lap 19 Open,
APR 13 Lap 13 Open
Hartley, 01 OLA/pr
LLA/pr
22
42
-
50%
125
180
LAR, APR, Hartmann
Anthuber, 03 OLA/pr
LLA/pr
334
101
-
11%
219
218
TME with colonic J if
<6cm
Breukink, 05 LAR
APR
10
31
NS 195
225
Double stapled
anastomosis
Laparoscopy: Rectal Cancer
Case controlled series for LAR
172. Laparoscopic vs. Open Surgery for
Extraperitoneal Rectal Cancer
• 191 consecutive patients
• 98 patients underwent lap resection
• 93 patients underwent open resection
Morino M, Surg Endosc 2005
173. Laparoscopic vs. Open Surgery
for Extraperitoneal Rectal Cancer
Laparoscopic
n = 98
Open
n = 93
P
Mean follow up (months) 46.3 49.7 NS
Conversion rate (%) 18.4
Mobilization (days) 1.7 3.3 < 0.001
Flatus (days) 2.6 3.9 < 0.001
Stool (days) 3.8 4.7 < 0.01
Oral intake (days) 3.4 4.8 < 0.001
Hospital stay (days) 11.4 13.0 NS
Morino M, Surg Endosc 2005
174. Laparoscopic vs. Open Surgery
for Extraperitoneal Rectal Cancer
Laparoscopic
n = 98
Open
n = 93
P
Morbidity (%) 24.4 23.6 NS
Mortality (%) 1.0 2.2 NS
Anastomotic leakage (%) 13.5 5.1 NS
Reoperation (%) 6.1 3.2 NS
Local recurrence (%) 3.2 12.6 < 0.05
Cumulative 5-year survival rate
(%)
80.0 68.9 NS
Disease-free 5-year survival rate
(%)
65.4 58.9 NS
Morino M, Surg Endosc 2005
175. Morino M, Surg Endosc 2005
Laparoscopic vs. Open Surgery
for Extraperitoneal Rectal Cancer
Conclusion
Laparoscopic resection for low and midrectal
cancer is characterized by faster recovery and
similar overall morbidity with no adverse
oncologic effect
176. Long – Term Results in Rectal Cancer
Lai JH, et al. Br Med Bull 2012
177. Conclusions
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 suggest
oncological safety.
180. NICE guidelines laparoscopic
colorectal cancer - August 2006
• Laparoscopic surgery is recommended as an
alternative to open surgery for colorectal
cancer…..
• The surgeon has been trained in laparoscopic
surgery for colorectal cancer and performs the
operation often enough to keep his skills up to
date