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Laparoscopic Surgery for Malignancy

PJ Shukla, PV Chitale, CS Ravichand
 

Introduction and Background
Since the first report of laparoscopic
cholecystectomy by Mouret in 1987 there is an upsurge of laparoscopic procedures for benign diseases such as laparoscopic cholecystectomy, Nissen’s fundoplication, inguinal hernia repair and appendicectomy.1 The initial successful and wide spread application of laparoscopic technique in benign diseases resulted in maturity of surgical skill and confidence in laparoscopy among the surgeons. This subsequently made surgeons apply laparoscopic technique for resection of malignant diseases.

Technological advances took rapid strides in last 20 years. With refinement in instrumentation and availability of newer energy sources laparoscopic resections in malignancy have become more successful and with fewer complications.

The main advantage of laparoscopic surgery over an open procedure is that it requires smaller incision, which translates into less pain, less pain medication, better cosmesis, earlier ambulation and quicker recovery.

Role of Laparoscopy in Malignancy
Laparoscopy is used in cases of malignancy as - diagnostic and staging procedure, therapeutic procedure, palliative procedure.

Laparoscopy is used either as
1) complete laparoscopy or as
2) hand assisted laparoscopy

Laparoscopy in Diagnosis and Staging of Malignancy
Despite the advances in imaging technology, conventional imaging techniques have been found to be inadequate in diagnosing and staging the disease in oncology.

Most important benefit of laparoscopy is to diagnose advanced disease without subjecting the patient to major exploration, associated pain and longer hospitalization. A non-therapeutic laparotomy adds cost, creates patient discomfort and delays alternative therapy till healing occurs. This is especially true in cases of peritoneal carcinomatosis which is easily missed on imaging. Ability of laparoscope of viewing deep and intricate structures, facility of laparoscopic biopsy and laparoscopic aided imaging (as laparoscopic ultrasound, doppler) is helpful in diagnosis and staging of retroperitoneal adenopathy, pancreatic tumours, adnexal masses, mesenteric tumours and the occult diseases in abdomen.

Ca Esophagus
Presence of distant nodal metastases and carcinomatosis contradicates the oesophageal resection. Non invasive imaging is found to overstage the disease in considerable proportion of patients, bereaving them of the curative resection. Thoraco-laparoscopy offers facility of accurate staging of lymph nodal disease by lymph node biopsy.

Gastric Cancer
The dismal prognosis associated with gastric cancer makes it essential to select the early cases in which a curative resection can be offered. Laparoscopy aids in the staging of gastric cancer by detecting peritoneal nodules, gastric serosal infiltration, adherence to adjacent structures, presence of lymph node metastases, presence of liver metastases, ascites and cytological evaluation of peritoneal washings.2 The laparoscopic staging accuracy in gastric cancer is about 90% and laparoscopy has been found to predict resectability in 87% of cases.

Hepato-Biliary and Pancreatic Tumours
Laparoscopic staging of liver tumours (primary and secondary) has low yield as compared to imaging. But Laparoscopic ultrasound (LUS) may prove to be helpful in deciding resectability of hepatic tumours.3 Laparoscopy is most accurate for identifying peritoneal disease and additional hepatic disease thereby preventing non therapeutic laparotomies. However, metastatic lesions below the capsule of liver and tumour invasion of the retroperitoneum and portal vein are the main considerations when determining local resectability. Laparoscopy combined with LUS is more specific in defining local resectability of pancreatic tumour.4

Laparoscopy in Treatment of Malignancy
Cancer surgery poses some unique challenges for the application of laparoscopy in oncology – a) relationship of a tumour to the tissues that surround it is critically important in cancer staging, specimens or whole organs should be removed intact (en bloc) so that the pathologists can properly examine them and measure and document the depths and margins of tumour invasion and resection, b) lack of evidence of improving outcomes of resections such as decreased hospital stay, decreased pain, early recovery, decreased costs, and earlier returns to work and c) any negative impact on survival e.g. induction of carcinomatosis, port site recurrences.

Oesophageal Cancer
During standard oesophageal resections, mobilization of oesophagus with mediastinal dissection is done thoracoscopically and gastric mobilization and resection is done laparoscopically. Avoidance of thoracotomy is thought to result in less pain and reduced respiratory complications

Gastric Cancer
Minimally invasive procedures include gastrectomy via laparoscopy and hand-assisted resections. Laparoscopic D1 gastrectomy seems ideal for early gastric cancer. A total D2 gastrectomy is advisable for middle- third and upper third lesions, but distal gastrectomy is sufficient for antral lesions.

Laparoscopic gastric resections are – a) Laparoscopic partial or total gastrectomy with internal reconstruction of upper GI tract b) Assisted laparoscopic partial or total gastrectomy – reconstruction is through minilaparotomy.

Pancreatic and Hepatobiliary Cancer
Pancreaticoduodenectomy, distal pancreate-ctomies, and liver resections are reported to be done laparoscopically. For liver malignancies, laparoscopic radiofrequency ablation and cryoablation under laparoscopic ultrasound guidance allow detection and treatment of small metastases.

Colorectal Cancer
All types of colonic and colorectal resection as anterior resection, abdominoperineal resection and total mesorectal excision are done laparoscopically. The laparoscopic procedure does not deviate from the steps of the traditional radical excision as it also includes high ligation of the vessels, adequate length of the distal margin from tumour, adequate lymphadenectomy and mesorectal excision. The resection margins and lymph node yield is not lower in laparoscopic procedure.5 The results of clinical outcome of surgical therapy (COST) trial suggest that laparoscopically assisted colectomies are equivalent to open colectomies in terms of recurrence and overall survival and have advantage of faster perioperative recovery.6

Laparoscopy in Palliation of Malignancy
Palliative procedures which are done laparoscopically are Gastro-Jejunostomy, Intestinal Bypass, Colostomy, Ileostomy, Feeding Jejunostomy / Gastrostomy.

Complications
Case selection is most important to reduce number of complications and conversion rate.

Injury to Adjacent Structures
In cancer patient infiltration of important structures by tumours makes such structures more susceptible for injury.

Port Site Herniation
Despite poor nutritional status and hypoalbuminaemia, the postoperative herniation through trocar site is not frequent in cancer patients. Closure of fascia at port site when it is of size more than 0.5 cm ensures this.

Complications related to the Learning curve
Laparoscopy is more than a new technique; it is a completely different way of operating. The visualization is different, the instruments are different, and the tactile aspects are very different. Intracorporeal suturing, for example, is a skill that requires a great deal of practice.

Port Site Recurrence
Port site metastasis (PSM) is recurrence of tumour at small wounds created for placement of ports during laparoscopy. The initial reported incidence of such recurrence ranged from 0 to 21%. Improved understanding of the mechanism of port site recurrences has prompted the surgeons to take appropriate precautions as e.g. use of plastic retrieval bag and use of non-touch technique during delivery of the specimen. This has reduced the incidence of port site recurrences to as low as less than 1%.

Conclusion
Over the past two decades laparoscopy has emerged as a valuable tool in the diagnosis and management of malignancy. The evolution of technology at hectic pace continues to confound the surgeon as we peruse the literature. There is no doubt that technological feasibility of executing major oncological procedures by laparoscopy has been established. Although long term oncologic safety is yet to be established in all laparoscopic procedures, short term outcomes are favourable and the issue of ‘port site’ recurrence seems to be waning.

References

  1. Stellato. History of Laparoscopic surgery. Surg Clin N Am 2001; 72 : 997.
  2. D’ugo DM, Pende V, Persian R, et al. Laparoscopic staging of gastric cancer: An overview. J Am Coll Surg 2003; 196 : 965.
  3. Pratt BL, Green FL. Role of Laparoscopy in the staging of Malignant disease. Surg Clin N Am 2000; 80 : 1111-26.
  4. Belagyi T, Olah A. Pancreatic head mass: What can be done? Diagnosis: Laparoscopy Journal of Pancreas 2000; 1 : 3.
  5. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopy assisted colectomies Vs open colectomies for the treatment of non-metastatic colon cancer. A randomized trial. Lancet 2002; 359 : 2224-9.
  6. Nelson H, Sargent DJ, Wieand SH, et al. A comparison of laparoscopically assisted and open colectomy for colon cancer. The clinical outcomes of surgical therapy study group. N Eng J Med 2004; 350 : 2050-9.

 
GI Surgical Services, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai.
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