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1.  Laparoscopic-assisted Colon Resections: Long-term Results and Survival 
Objective:
We reviewed the long-term results and patient survival for laparoscopic-assisted resection of colorectal malignancies. The place of laparoscopic colectomy for colorectal carcinomas is controversial. The techniques and expected surgical outcomes for patients undergoing laparoscopic and laparoscopic-assisted colectomies are being defined as these procedures become more acceptable and reach parity with, or even surpass, results of traditional operations. Anecdotal reports in the literature describe port-site and incisional tumor implantation in patients undergoing laparoscopic-assisted colectomies for colorectal malignancies. This raises concerns about whether these incisional tumor sites are more common in these patients and whether their survival is compromised by the laparoscopic technique.
Methods:
The authors reviewed data from 110 patients who underwent laparoscopic-assisted colectomies for colorectal cancer to determine the long-term results and survival and to compare the safety and efficacy of laparoscopic-assisted colectomy to the safety and efficacy of open colectomy. Between July 1991 and June 1999, 350 patients underwent laparoscopic-assisted colectomies. Of these, 110 patients had colorectal malignancies. Survival rates and patterns of recurrence were compared within the various TNM stages and compared with conventional data after open surgery. The American Joint Committee on Cancer staging for colorectal carcinomas and the Kaplan-Meier method were used to determine the survival curves.
Results:
Laparoscopic-assisted colon resections for colorectal malignancies were performed in 110 patients. Fifty-one percent of the patients were women, and 49% percent were men, with a mean age of 78.17 years. The mean follow-up was 43 months. Thirteen patients were converted to open operation due to various difficulties encountered during the procedure. Mean operative time was 128.16 minutes, and mean hospital stay was 6.91 days. Perioperative mortality was 2.77%. There were 4 local recurrences. The ten-year survival rates for the various stages were 78% for stage I, 33% for stage II, 30% for stage III, and 0% for stage IV. No port-site implantations occurred.
Conclusion:
Laparoscopic-assisted colon resection of colorectal carcinomas is technically feasible and safe. It allows earlier postoperative recovery and a shorter hospital stay. The long-term survival is also satisfactory. The incidence of port-site implants is no more than that with the conventional open technique. Determination of any benefits over the conventional open technique, however, still await prospective randomized trials.
PMCID: PMC3015573  PMID: 15984707
Laparoscopic colon resections; Laparoscopic-assisted colon resections; Colorectal malignancies
2.  Surgical and pathological outcomes of laparoscopic surgery for transverse colon cancer 
Purpose
Several multi-institutional prospective randomized trials have demonstrated short-term benefits using laparoscopy. Now the laparoscopic approach is accepted as an alternative to open surgery for colon cancer. However, in prior trials, the transverse colon was excluded. Therefore, it has not been determined whether laparoscopy can be used in the setting of transverse colon cancer. This study evaluated the peri-operative clinical outcomes and oncological quality by pathologic outcomes of laparoscopic surgery for transverse colon cancer.
Materials and methods
Analysis of the medical records of patients who underwent laparoscopic colorectal resection from August 2004 to November 2007 was made. Computed tomography, barium enema, and colonoscopy were performed to localize the tumor preoperatively. Extended right hemicolectomy, transverse colectomy, and extended left hemicolectomy were performed for transverse colon cancer. Surgical outcomes and pathologic outcomes were compared between transverse colon cancer (TCC) and other site colon cancer (OSCC).
Results
Of the 312 colorectal cancer patients, 94 patients underwent laparoscopic surgery for OSCC, and 34 patients underwent laparoscopic surgery for TCC. Patients with TCC were similar to patients with OSCC in age, gender, body mass index, operating time, blood loss, time to pass flatus, start of diet, hospital stay, tumor size, distal resection margin, proximal resection margin, number of lymph nodes, and radial margin. One case in TCC and three cases in OSCC were converted to open surgery.
Conclusions
Laparoscopic surgery for transverse colon cancer and OSCC had similar peri-operative clinical and acceptable pathological outcomes.
doi:10.1007/s00384-008-0471-7
PMCID: PMC2386750  PMID: 18379794
Laparoscopy; Transverse colon; Colon cancer
3.  Laparoscopic Colectomy for Colon Cancer: Comparable to Conventional Oncologic Surgery? 
ABSTRACT
As a result of the obvious benefits of laparoscopic cholecystectomy, minimally invasive techniques have been applied to more complex gastrointestinal procedures, including colorectal resections. The goal in adapting laparoscopic techniques for colorectal surgery is to offer an operation that results in less pain, shorter hospital stay, more rapid return to normal activities, and improved cosmesis compared with conventional operation. The challenge has been to show that this can be done safely and efficiently and that for cancer patients there is no detrimental oncologic effect. The major issues that have been and continue to be addressed are (1) whether an adequate resection can be performed laparoscopically, (2) whether there is a high rate of wound or port site recurrence following these operations, and (3) whether, by using these techniques, we are trading short-term benefits for a poor long-term oncologic outcome. To answer these fundamental questions, several prospective randomized trials have been conducted and several more are under way. The results of these trials indicate that, in terms of cancer outcome, there is no difference in overall survival, disease-free survival, and wound recurrences in patients treated using laparoscopic techniques compared with conventional operation. In addition, there are short-term benefits associated with the use of these techniques. It can now be said that from an oncologic standpoint, in experienced hands, laparoscopic colectomy for curable colon cancer is equivalent to conventional therapy, and it is superior to conventional operation regarding short-term outcomes. Laparoscopic colectomy for colon cancer should be offered to appropriately selected patients.
doi:10.1055/s-2005-916278
PMCID: PMC2780093  PMID: 20011300
Laparoscopy; colon cancer; laparoscopic colectomy
4.  Robotic-Assisted Minimally Invasive Surgery for Gynecologic and Urologic Oncology 
Executive Summary
Objective
An application was received to review the evidence on the ‘The Da Vinci Surgical System’ for the treatment of gynecologic malignancies (e.g. endometrial and cervical cancers). Limitations to the current standard of care include the lack of trained physicians on minimally invasive surgery and limited access to minimally invasive surgery for patients. The potential benefits of ‘The Da Vinci Surgical System’ include improved technical manipulation and physician uptake leading to increased surgeries, and treatment and management of these cancers.
The demand for robotic surgery for the treatment and management of prostate cancer has been increasing due to its alleged benefits of recovery of erectile function and urinary continence, two important factors of men’s health. The potential technical benefits of robotic surgery leading to improved patient functional outcomes are surgical precision and vision.
Clinical Need
Uterine and cervical cancers represent 5.4% (4,400 of 81,700) and 1.6% (1,300 of 81,700), respectively, of incident cases of cancer among female cancers in Canada. Uterine cancer, otherwise referred to as endometrial cancer is cancer of the lining of the uterus. The most common treatment option for endometrial cancer is removing the cancer through surgery. A surgical option is the removal of the uterus and cervix through a small incision in the abdomen using a laparoscope which is referred to as total laparoscopic hysterectomy. Risk factors that increase the risk of endometrial cancer include taking estrogen replacement therapy after menopause, being obese, early age at menarche, late age at menopause, being nulliparous, having had high-dose radiation to the pelvis, and use of tamoxifen.
Cervical cancer occurs at the lower narrow end of the uterus. There are more treatment options for cervical cancer compared to endometrial cancer, however total laparoscopic hysterectomy is also a treatment option. Risk factors that increase the risk for cervical cancer are multiple sexual partners, early sexual activity, infection with the human papillomavirus, and cigarette smoking, whereas barrier-type of contraception as a risk factor decreases the risk of cervical cancer.
Prostate cancer is ranked first in men in Canada in terms of the number of new cases among all male cancers (25,500 of 89,300 or 28.6%). The impact on men who develop prostate cancer is substantial given the potential for erectile dysfunction and urinary incontinence. Prostate cancer arises within the prostate gland, which resides in the male reproductive system and near the bladder. Radical retropubic prostatectomy is the gold standard treatment for localized prostate cancer. Prostate cancer affects men above 60 years of age. Other risk factors include a family history of prostate cancer, being of African descent, being obese, consuming a diet high in fat, physical inactivity, and working with cadium.
The Da Vinci Surgical System
The Da Vinci Surgical System is a robotic device. There are four main components to the system: 1) the surgeon’s console, where the surgeon sits and views a magnified three-dimensional image of the surgical field; 2) patient side-cart, which sits beside the patient and consists of three instrument arms and one endoscope arm; 3) detachable instruments (endowrist instruments and intuitive masters), which simulate fine motor human movements. The hand movements of the surgeon’s hands at the surgeon’s console are translated into smaller ones by the robotic device and are acted out by the attached instruments; 4) three-dimensional vision system: the camera unit or endoscope arm. The main advantages of use of the robotic device are: 1) the precision of the instrument and improved dexterity due to the use of “wristed” instruments; 2) three-dimensional imaging, with improved ability to locate blood vessels, nerves and tissues; 3) the surgeon’s console, which reduces fatigue accompanied with conventional laparoscopy surgery and allows for tremor-free manipulation. The main disadvantages of use of the robotic device are the costs including instrument costs ($2.6 million in US dollars), cost per use ($200 per use), the costs associated with training surgeons and operating room personnel, and the lack of tactile feedback, with the trade-off being increased visual feedback.
Research Questions
For endometrial and cervical cancers,
1. What is the effectiveness of the Da Vinci Surgical System vs. laparoscopy and laparotomy for women undergoing any hysterectomy for the surgical treatment and management of their endometrial and cervical cancers?
2. What are the incremental costs of the Da Vinci Surgical System vs. laparoscopy and laparotomy for women undergoing any hysterectomy for the surgical treatment and management of their endometrial and cervical cancers?
For prostate cancer,
3. What is the effectiveness of robotically-assisted radical prostatectomy using the Da Vinci Surgical System vs. laparoscopic radical prostatectomy and retropubic radical prostatectomy for the surgical treatment and management of prostate cancer?
4. What are the incremental costs of robotically-assisted radical prostatectomy using the Da Vinci Surgical System vs. laparoscopic radical prostatectomy and retropubic radical prostatectomy for the surgical treatment and management of prostate cancer?
Research Methods
Literature Search
Search Strategy
A literature search was performed on May 12, 2010 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, Wiley Cochrane, CINAHL, Centre for Reviews and Dissemination/International Agency for Health Technology Assessment for studies published from January 1, 2000 until May 12, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search. Articles with unknown eligibility were reviewed with a second clinical epidemiologist, then a group of epidemiologists until consensus was established. The quality of evidence was assessed as high, moderate, low or very low according to GRADE methodology.
Inclusion Criteria
English language articles (January 1, 2000-May 12, 2010)
Journal articles that report on the effectiveness or cost-effectiveness for the comparisons of interest using a primary data source (e.g. obtained in a clinical setting)
Journal articles that report on the effectiveness or cost-effectiveness for the comparisons of interest using a secondary data source (e.g. hospital- or population-based registries)
Study design and methods must be clearly described
Health technology assessments, systematic reviews, randomized controlled trials, non-randomized controlled trials and/or cohort studies, case-case studies, regardless of sample size, cost-effectiveness studies
Exclusion Criteria
Duplicate publications (with the more recent publication on the same study population included)
Non-English papers
Animal or in-vitro studies
Case reports or case series without a referent or comparison group
Studies on long-term survival which may be affected by treatment
Studies that do not examine the cancers (e.g. advanced disease) or outcomes of interest
Outcomes of Interest
For endometrial and cervical cancers,
Primary outcomes:
Morbidity factors
- Length of hospitalization
- Number of complications*
Peri-operative factors
- Operation time
- Amount of blood loss*
- Number of conversions to laparotomy*
Number of lymph nodes recovered
For prostate cancer,
Primary outcomes:
Morbidity factors
- Length of hospitalization
- Amount of morphine use/pain*
Peri-operative factors
- Operation time
- Amount of blood loss*
- Number of transfusions*
- Duration of catheterization
- Number of complications*
- Number of anastomotic strictures*
Number of lymph nodes recovered
Oncologic factors
- Proportion of positive surgical margins
Long-term outcomes
- Urinary continence
- Erectile function
Summary of Findings
Robotic use for gynecologic oncology compared to:
Laparotomy: benefits of robotic surgery in terms of shorter length of hospitalization and less blood loss. These results indicate clinical effectiveness in terms of reduced morbidity and safety, respectively, in the context of study design limitations.
The beneficial effect of robotic surgery was shown in pooled analysis for complications, owing to increased sample size.
More work is needed to clarify the role of complications in terms of safety, including improved study designs, analysis and measurement.
Laparoscopy: benefits of robotic surgery in terms of shorter length of hospitalization, less blood loss and fewer conversions to laparotomy likely owing to the technical difficulty of conventional laparoscopy, in the context of study design limitations.
Clinical significance of significant findings for length of hospitalizations and blood loss is low.
Fewer conversions to laparotomy indicate clinical effectiveness in terms of reduced morbidity.
Robotic use for urologic oncology, specifically prostate cancer, compared to:
Retropubic surgery: benefits of robotic surgery in terms of shorter length of hospitalization and less blood loss/fewer individuals requiring transfusions. These results indicate clinical effectiveness in terms of reduced morbidity and safety, respectively, in the context of study design limitations. There was a beneficial effect in terms of decreased positive surgical margins and erectile dysfunction. These results indicate clinical effectiveness in terms of improved cancer control and functional outcomes, respectively, in the context of study design limitations.
Surgeon skill had an impact on cancer control and functional outcomes.
The results for complications were inconsistent when measured as either total number of complications, pain management or anastomosis. There is some suggestion that robotic surgery is safe with respect to less post-operative pain management required compared to retropubic surgery, however improved study design and measurement of complications need to be further addressed.
Clinical significance of significant findings for length of hospitalizations is low.
Laparoscopy: benefits of robotic surgery in terms of less blood loss and fewer individuals requiring transfusions likely owing to the technical difficulty of conventional laparoscopy, in the context of study design limitations.
Clinical significance of significant findings for blood loss is low.
The potential link between less blood loss, improved visualization and improved functional outcomes is an important consideration for use of robotics.
All studies included were observational in nature and therefore the results must be interpreted cautiously.
Economic Analysis
The objective of this project was to assess the economic impact of robotic-assisted laparoscopy (RAL) for endometrial, cervical, and prostate cancers in the province of Ontario.
A budget impact analysis was undertaken to report direct costs associated with open surgery (OS), endoscopic laparoscopy (EL) and robotic-assisted laparoscopy (RAL) based on clinical literature review outcomes, to report a budget impact in the province based on volumes and costs from administrative data sets, and to project a future impact of RAL in Ontario. A cost-effectiveness analysis was not conducted because of the low quality evidence from the clinical literature review.
Hospital costs were obtained from the Ontario Case Costing Initiative (OCCI) for the appropriate Canadian Classification of Health Intervention (CCI) codes restricted to selective ICD-10 diagnostic codes after consultation with experts in the field. Physician fees were obtained from the Ontario Schedule of Benefits (OSB) after consultation with experts in the field. Fees were costed based on operation times reported in the clinical literature for the procedures being investigated. Volumes of procedures were obtained from the Ministry of Health and Long-Term Care (MOHLTC) administrative databases.
Direct costs associated with RAL, EL and OS included professional fees, hospital costs (including disposable instruments), radiotherapy costs associated with positive surgical margins in prostate cancer and conversion to OS in gynecological cancer. The total cost per case was higher for RAL than EL and OS for both gynecological and prostate cancers. There is also an acquisition cost associated with RAL. After conversation with the only supplier in Canada, hospitals are looking to spend an initial 3.6M to acquire the robotic surgical system
Previous volumes of OS and EL procedures were used to project volumes into Years 1-3 using a linear mathematical expression. Burden of OS and EL hysterectomies and prostatectomies was calculated by multiplying the number of cases for that year by the cost/case of the procedure.
The number of procedures is expected to increase in the next three years based on historical data. RAL is expected to capture this market by 65% after consultation with experts. If it’s assumed that RAL will capture the current market in Ontario by 65%, the net impact is expected to be by Year 3, 3.1M for hysterectomy and 6.7M for prostatectomy procedures respectively in the province.
RAL has diffused in the province with four surgical systems in place in Ontario, two in Toronto and two in London. RAL is a more expensive technology on a per case basis due to more expensive robot specific instrumentation and physician labour reflected by increased OR time reported in the clinical literature. There is also an upfront cost to acquire the machine and maintenance contract. RAL is expected to capture the market at 65% with project net impacts by Year 3 of 3.1M and 6.7M for hysterectomy and prostatectomy respectively.
PMCID: PMC3382308  PMID: 23074405
5.  Laparoscopic surgery for rectal cancer: The state of the art 
At present time, there is evidence from randomized controlled studies of the success of laparoscopic resection for the treatment of colon cancer with reported smaller incisions, lower morbidity rate and earlier recovery compared to open surgery. Technical limitations and a steep learning curve have limited the wide application of mini-invasive surgery for rectal cancer. The present article discusses the current status of laparoscopic resection for rectal cancer. A review of the more recent retrospective, prospective and randomized controlled trial (RCT) data on laparoscopic resection of rectal cancer including the role of trans-anal endoscopic microsurgery and robotics was performed. A particular emphasis was dedicated to mid and low rectal cancers. Few prospective and RCT trials specifically addressing laparoscopic rectal cancer resection are currently available in the literature. Improved short-term outcomes in term of lesser intraoperative blood loss, reduced analgesic requirements and a shorter hospital stay have been demonstrated. Concerns have recently been raised in the largest RCT trial of the oncological adequacy of laparoscopy in terms of increased rate of circumferential margin. This data however was not confirmed by other prospective comparative studies. Moreover, a similar local recurrence rate has been reported in RCT and comparative series. Similar findings of overall and disease free survival have been reported but the follow-up time period is too short in all these studies and the few RCT trials currently available do not draw any definitive conclusions. On the basis of available data in the literature, the mini-invasive approach to rectal cancer surgery has some short-term advantages and does not seem to confer any disadvantage in term of local recurrence. With respect to long-term survival, a definitive answer cannot be given at present time as the results of RCT trials focused on long-term survival currently ongoing are still to fully clarify this issue.
doi:10.4240/wjgs.v2.i9.275
PMCID: PMC2999691  PMID: 21160896
Postoperative complications; Recurrence rate; Transanal endoscopic microsurgery; Robotics; Long-term outcome; Prognosis; Rectal cancer; Laparoscopy
6.  Single incision laparoscopic colorectal resection: Our experience 
BACKGROUND:
A prospective case series of single incision multiport laparoscopic colorectal resections for malignancy using conventional laparoscopic trocars and instruments is described.
MATERIALS AND METHODS:
Eleven patients (seven men and four women) with colonic or rectal pathology underwent single incision multiport laparoscopic colectomy/rectal resection from July till December 2010. Four trocars were placed in a single transumblical incision. The bowel was mobilized laparoscopically and vessels controlled intracorporeally with either intra or extracorporeal anastomosis.
RESULTS:
Three patients had carcinoma in the caecum, one in the hepatic flexure, two in the rectosigmoid, one in the descending colon, two in the rectum and two had ulcerative pancolitis (one with high grade dysplasia and another with carcinoma rectum). There was no conversion to standard multiport laparoscopy or open surgery. The median age was 52 years (range 24-78 years). The average operating time was 130 min (range 90-210 min). The average incision length was 3.2 cm (2.5-4.0 cm). There were no postoperative complications. The average length of stay was 4.5 days (range 3-8 days). Histopathology showed adequate proximal and distal resection margins with an average lymph node yield of 25 nodes (range 16-30 nodes).
CONCLUSION:
Single incision multiport laparoscopic colorectal surgery for malignancy is feasible without extra cost or specialized ports/instrumentation. It does not compromise the oncological radicality of resection. Short-term results are encouraging. Long-term results are awaited.
doi:10.4103/0972-9941.103118
PMCID: PMC3523450  PMID: 23248440
Laparoscopic colectomy; single incision laparoscopic surgery; single incision
7.  Technique of sentinel lymph node biopsy and lymphatic mapping during laparoscopic colon resection for cancer 
Background:
The utility of lymph node mapping to improve staging in colon cancer is still under evaluation. Laparoscopic colectomy for colon cancer has been validated in multi-centric trials. This study assessed the feasibility and technical aspects of lymph node mapping in laparoscopic colectomy for colon cancer.
Methods:
A total of 42 patients with histologically proven colon cancer were studied from January 2006 to September 2007. Exclusion criteria were: advanced disease (clinical stage III), rectal cancer, previous colon resection and contraindication to laparoscopy. Lymph-nodal status was assessed preoperatively by computed tomography (CT) scan and intra-operatively with the aid of laparoscopic ultrasound. Before resection, 2–3 ml of Patent Blue V dye was injected sub-serosally around the tumour. Coloured lymph nodes were marked as sentinel (SN) with metal clips or suture and laparoscopic colectomy with lymphadenectomy completed as normal. In case of failure of the intra-operative procedure, an ex vivo SN biopsy was performed on the colectomy specimen after resection.
Results:
A total number of 904 lymph nodes were examined, with a median number of 22 lymph nodes harvested per patient. The SN detection rate was 100%, an ex vivo lymph node mapping was necessary in four patients. Eleven (26.2%) patients had lymph-nodal metastases and in five (45.5%) of these patients, SN was the only positive lymph node. There were two (18.2%) false-negative SN. In three cases (7.1%) with aberrant lymphatic drainage, lymphadenectomy was extended. The accuracy of SN mapping was 95.2% and negative predictive value was 93.9%.
Conclusions:
Laparoscopic lymphatic mapping and SN removal is feasible in laparoscopic colectomy for colon cancer. The ex vivo technique is useful as a salvage technique in case of failure of the intra-operative procedure. Prospective studies are justified to determine the real accuracy and false-negative rate of the technique.
doi:10.3332/ecancer.2008.60
PMCID: PMC3223971  PMID: 22275957
8.  Laparoscopic versus open colectomy for colon cancer in an older population: a cohort study 
Background
Laparoscopic colectomy for colon cancer has been compared with open colectomy in randomized controlled trials, but these studies may not be generalizable because of strict enrollment and exclusion criteria which may explicitly or inadvertently exclude older individuals due to associated comorbidities. Previous studies of older patients undergoing laparoscopic colectomy have generally focused on short-term outcomes. The goals of this cohort study were to identify predictors of laparoscopic colectomy in an older population in the United States and to compare short-term and long-term outcomes.
Methods
Patients aged 65 years or older with incident colorectal cancer diagnosed 1996-2002 who underwent colectomy within 6 months of cancer diagnosis were identified from the linked Surveillance, Epidemiology, and End Results-Medicare database. Laparoscopic and open colectomy patients were compared with respect to length of stay, blood transfusion requirements, intensive care unit monitoring, complications, 30-day mortality, and long-term survival. We adjusted for potential selection bias in surgical approach with propensity score matching.
Results
Laparoscopic colectomy cases were associated with left-sided tumors; areas with higher population density, income, and education level; areas in the western United States; and National Cancer Institute-designated cancer centers. Laparoscopic colectomy cases had shorter length of stay and less intensive care unit monitoring. Although laparoscopic colectomy patients (n = 424) had fewer complications (21.5% versus 26.3%), lower 30-day mortality (3.3% versus 5.8%), and longer median survival (6.6 versus 4.8 years) compared with open colectomy patients (n = 27,012), after propensity score matching these differences disappeared.
Conclusions
In this older population, laparoscopic colectomy practice patterns were associated with factors which likely correlate with tertiary referral centers. Although short-term and long-term survival are comparable, laparoscopic colectomy offers shorter hospitalizations and less intensive care.
doi:10.1186/1477-7819-10-31
PMCID: PMC3296595  PMID: 22313593
9.  Laparoscopic rectal cancer surgery: Where do we stand? 
Large comparative studies and multiple prospective randomized control trials (RCTs) have reported equivalence in short and long-term outcomes between the open and laparoscopic approaches for the surgical treatment of colon cancer which has heralded widespread acceptance for laparoscopic resection of colon cancer. In contrast, laparoscopic total mesorectal excision (TME) for the treatment of rectal cancer has been welcomed with significantly less enthusiasm. While it is likely that patients with rectal cancer will experience the same benefits of early recovery and decreased postoperative pain from the laparoscopic approach, whether the same oncologic clearance, specifically an adequate TME can be obtained is of concern. The aim of the current study is to review the current level of evidence in the literature on laparoscopic rectal cancer surgery with regard to short-term and long-term oncologic outcomes. The data from 8 RCTs, 3 meta-analyses, and 2 Cochrane Database of Systematic Reviews was reviewed. Current data suggests that laparoscopic rectal cancer resection may benefit patients with reduced blood loss, earlier return of bowel function, and shorter hospital length of stay. Concerns that laparoscopic rectal cancer surgery compromises short-term oncologic outcomes including number of lymph nodes retrieved and circumferential resection margin and jeopardizes long-term oncologic outcomes has not conclusively been refuted by the available literature. Laparoscopic rectal cancer resection is feasible but whether or not it compromises short-term or long-term results still needs to be further studied.
doi:10.3748/wjg.v18.i46.6747
PMCID: PMC3520163  PMID: 23239912
Rectal cancer; Laparoscopy; Total mesorectal excision; Anterior resection; Abdominoperineal resection
10.  Laparoscopic surgery for colorectal cancers: Current status 
Laparoscopy was introduced more than 15 years ago into clinical practice. However, its role in colorectal surgery was not well established for want of better skills and technology. This coupled with high incidences of port site recurrences, prevented laparoscopic surgery from being incorporated into mainstream colorectal cancer surgery. A recent increase in the number of reports, retrospective analyses, randomized trials and multicentric trials has now provided sufficient data to support the role of laparoscopy in colorectal cancer surgery. We, thus, present a review of the published data on the feasibility, safety, short - and long-term outcomes following laparoscopic surgery for colorectal cancers. While the data available strongly favors the use of laparoscopic surgery in colonic cancer, larger well powered studies are required to prove or disprove its role in rectal cancer.
doi:10.4103/0972-9941.28181
PMCID: PMC3016481  PMID: 21234147
Colorectal cancer; colorectal surgery; laparoscopic surgery
11.  Laparoscopic Resection for Rectal Cancer: What Is the Evidence? 
BioMed Research International  2014;2014:347810.
Laparoscopic colectomy for colon cancer is a well-established procedure supported by several well-conducted large-scale randomised controlled trials. Patients could now be conferred the benefits of the minimally invasive approach while retaining comparable oncologic outcomes to the open approach. However, the benefits of laparoscopic proctectomy for rectal cancer remained controversial. While the laparoscopic approach is more technically demanding, results from randomised controlled trials regarding long term oncologic outcomes are only beginning to be reported. The impacts of bladder and sexual functions following proctectomy are considerable and are important contributing factors to the patients' quality of life in the long-term. These issues present a delicate dilemma to the surgeon in his choice of operative approach in tackling rectal cancer. This is compounded further by the rapid proliferation of various laparoscopic techniques including the hand assisted, robotic assisted, and single port laparoscopy. This review article aims to draw on the significant studies which have been conducted to highlight the short- and long-term outcomes and evidence for laparoscopic resection for rectal cancer.
doi:10.1155/2014/347810
PMCID: PMC4009228  PMID: 24822196
12.  Laparoscopic and open resection for colorectal cancer: an evaluation of cellular immunity 
BMC Gastroenterology  2010;10:127.
Background
Colorectal cancer is one kind of frequent malignant tumors of the digestive tract which gets high morbidity and mortality allover the world. Despite the promising clinical results recently, less information is available regarding the perioperative immunological effects of laparoscopic surgery when compared with the open surgery. This study aimed to compare the cellular immune responses of patients who underwent laparoscopic(LCR) and open resections(OCR) for colorectal cancer.
Methods
Between Mar 2009 and Sep 2009, 35 patients with colorectal carcinoma underwent LCR by laparoscopic surgeon. These patients were compared with 33 cases underwent conventional OCR by colorectal surgeon. Clinical data about the patients were collected prospectively. Comparison of the operative details and postoperative outcomes between laparoscopic and open resection was performed. Peripheral venous blood samples from these 68 patients were taken prior to surgery as well as on postoperative days(POD) 1, 4 and 7. Cell counts of total white blood cells, neutrophils, lymphocyte subpopulations, natural killer(NK) cells as well as CRP were determined by blood counting instrument, flow cytometry and hematology analyzer.
Results
There was no difference in the age, gender and tumor status between the two groups. The operating time was a little longer in the laparoscopic group (P > 0.05), but the blood loss was less (P = 0.039). Patients with laparoscopic resection had earlier return of bowel function and earlier resumption of diet as well as shorter median hospital stay (P < 0.001). Compared with OCR group, cell numbers of total lymphocytes, CD4+T cells and CD8+T cells were significant more in LCR group (P < 0.05) on POD 4, while there was no difference in the CD45RO+T or NK cell numbers between the two groups. Cellular immune responds were similar between the two groups on POD1 and POD7.
Conclusions
Laparoscopic colorectal resection gets less surgery stress and short-term advantages compared with open resection. Cellular immune respond appears to be less affected by laparoscopic colorectal resection when compared with open resection.
doi:10.1186/1471-230X-10-127
PMCID: PMC2988071  PMID: 21029461
13.  Synchronous resections of primary colorectal tumor and liver metastasis by laparoscopic approach 
World Journal of Hepatology  2013;5(6):298-301.
Liver metastasis of colorectal cancer is common. Resection of solitary tumors of primary and metastatic colorectal cancer can have a favorable outcome. Open resection of primary colorectal tumor and liver metastasis in one operation or in separate operations is currently common practice. Reports have shown that synchronous resections do not jeopardize short or long-term surgical outcomes and that this is a safe and effective approach in open surgery. The development of laparoscopic colorectal surgery and laparoscopic hepatectomy has made a minimally invasive surgical approach to treating colorectal cancer with liver metastasis feasible. Synchronous resections of primary colorectal tumor and liver metastasis by laparoscopy have recently been reported. The efficacy and safety of laparoscopic colorectal resection and laparoscopic hepatectomy have been proven separately but synchronous resections by laparoscopy are in hot debate. As it has been shown that open resection of primary colorectal tumor and liver metastasis in one operation results in an equally good short-term outcome when compared with that done in separate operations, laparoscopic resection of the same in one single operation seems to be a good option. Recent evidence has shown that this new approach is a safe alternative with a shorter hospital stay. Large scale randomized controlled trials are needed to demonstrate the effectiveness of this minimally invasive approach.
doi:10.4254/wjh.v5.i6.298
PMCID: PMC3692970  PMID: 23805353
Colorectal cancer; Hepatectomy; Laparoscopic; Liver resection; Simultaneous; Synchronous
14.  Perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care (LAFA trial) 
BMC Surgery  2006;6:16.
Background
Recent developments in large bowel surgery are the introduction of laparoscopic surgery and the implementation of multimodal fast track recovery programs. Both focus on a faster recovery and shorter hospital stay.
The randomized controlled multicenter LAFA-trial (LAparoscopy and/or FAst track multimodal management versus standard care) was conceived to determine whether laparoscopic surgery, fast track perioperative care or a combination of both is to be preferred over open surgery with standard care in patients having segmental colectomy for malignant disease.
Methods/design
The LAFA-trial is a double blinded, multicenter trial with a 2 × 2 balanced factorial design. Patients eligible for segmental colectomy for malignant colorectal disease i.e. right and left colectomy and anterior resection will be randomized to either open or laparoscopic colectomy, and to either standard care or the fast track program. This factorial design produces four treatment groups; open colectomy with standard care (a), open colectomy with fast track program (b), laparoscopic colectomy with standard care (c), and laparoscopic surgery with fast track program (d). Primary outcome parameter is postoperative hospital length of stay including readmission within 30 days. Secondary outcome parameters are quality of life two and four weeks after surgery, overall hospital costs, morbidity, patient satisfaction and readmission rate.
Based on a mean postoperative hospital stay of 9 +/- 2.5 days a group size of 400 patients (100 each arm) can reliably detect a minimum difference of 1 day between the four arms (alfa = 0.95, beta = 0.8). With 100 patients in each arm a difference of 10% in subscales of the Short Form 36 (SF-36) questionnaire and social functioning can be detected.
Discussion
The LAFA-trial is a randomized controlled multicenter trial that will provide evidence on the merits of fast track perioperative care and laparoscopic colorectal surgery in patients having segmental colectomy for malignant disease.
doi:10.1186/1471-2482-6-16
PMCID: PMC1693570  PMID: 17134506
15.  Hospital-level outcomes associated with laparoscopic colectomy for cancer in the minimally invasive era 
Background
Compared to the open approach, randomized trials have shown that laparoscopic colectomy is associated with a shorter hospitalization without increases in morbidity or mortality rates. With broader adoption of laparoscopic colectomy for cancer in the United States, it is unclear if laparoscopic colectomy continues to be associated with shorter hospitalization and comparable morbidity.
Purpose
To determine if hospitals where a greater proportion of colon resections for cancer are approached laparoscopically (laparoscopy rate) achieve improved short-term outcomes compared to hospitals with lower laparoscopy rates.
Methods
From the 2008–2009 Nationwide Inpatient Sample, we identified hospitals where ≤12 colon resections for cancer where reported with ≥1 approached laparoscopically. We assessed the correlation between a hospital’s laparoscopy rate and risk-standardized outcomes (intra- and post-operative morbidity, in-hospital mortality rates, and average length of stay).
Results
Overall, 6,806 colon resections were performed at 276 hospitals. Variation was noted in hospital laparoscopy rates (median=52.0%, range=3.8–100%) and risk-standardized intra- (2.7%, 1.8–8.6%) and post-operative morbidity (27.8%, 16.4–53.4%), in-hospital mortality (0.7%, 0.3–42.0%), and average length of stay (7.0 days, 4.9–10.3 days). While no association was noted with in-hospital mortality, higher laparoscopy rates were correlated with lower post-operative morbidity (correlation coefficient [r]=−0.12, p=0.04) and shorter hospital stays (r=−0.23, p<0.001), but higher intra-operative morbidity (r=0.19, p<0.001) rates. This was not observed among hospitals with high procedure volumes.
Conclusions
Higher laparoscopy rates were associated with only slightly lower post-operative morbidity rates and modestly shorter hospitalizations.
doi:10.1007/s11605-012-2018-z
PMCID: PMC3670114  PMID: 22948842
Laparoscopic colectomy; surgical outcomes
16.  The Role of Minimally Invasive Surgery and Outcomes in Colorectal Cancer 
The Permanente Journal  2011;15(3):61-66.
For some time now, there has been significant interest in understanding and defining the role of minimally invasive surgery in colorectal cancer. Laparoscopic surgery has been shown to have similar or better outcomes compared with open surgery. Recently, prospective randomized trials have demonstrated oncologic outcomes of laparoscopic colon surgery equivalent to those for open surgery. However, the technical challenges of performing laparoscopic resection of rectal cancers and the uncertainty of the oncologic quality of the surgical resection have hindered the growth of minimally invasive rectal surgery. Robotic rectal surgery has recently emerged as an attractive alternative to laparoscopic surgery because it allows for superior visualization within a narrow pelvic field and more precise dissection. Studies of robotic rectal resection have suggested similar or potentially improved short-term oncologic outcomes when compared with laparoscopic rectal resection. Ongoing randomized studies will provide additional insight into the role of laparoscopic and minimally invasive robotic surgery for rectal cancer.
PMCID: PMC3200102  PMID: 22058671
17.  Laparoscopic Colorectal Surgery: An Update (with Special Reference to Indian Scenario) 
Laparoscopic cholecystectomy, being already declared as gold standard technique, laparoscopic surgery has advanced far and wide, touching almost every corner of the abdomen. This advancement has gradually expanded to colorectal surgery which is done for malignant diseases as well. However, laparoscopic colorectal surgery has not been accepted as quickly as was laparoscopic cholecystectomy. This is because of its steep learning curve, concerns with oncological outcomes, lack of randomized control trials (RCTs) and initial reports on high port site recurrences which occurred after curative resections. But all these initial concerns have been overcome by doing a series of RCTs globally, in the past decade, that revealed that laparoscopic colorectal surgery for malignant disease offered short term benefits without compromising on oncological principles of radicality of resection, tumour resection margins and completeness of lymph node harvesting as compared to those of open surgery. Favourable post-operative results with respect to less blood loss, less pain, lesser surgical site infections, lesser requirement of analgesics, early return of bowel function and shorter hospital stay in patients who underwent laparoscopic colorectal resections were obtained in studies done on individual series, including those done in India and more recently, in large trials. An update on recent studies done on laparoscopic colorectal surgery by reviewing many RCTs and individual series, including our experiences, was made, to support the advantages of this procedure which were obtained when it was carried out by skilled hands.
doi:10.7860/JCDR/2014/8269.4285
PMCID: PMC4064916  PMID: 24959478
Laparoscopic colorectal surgery; RCTs; Review; Personal series; Advantages
18.  Single-Port Laparoscopic Surgery for Inflammatory Bowel Disease 
Minimally Invasive Surgery  2012;2012:106878.
Background. Single Port Laparoscopic Surgery (SPLS) is being increasingly employed in colorectal surgery for benign and malignant diseases. The particular role for SPLS in inflammatory bowel disease (IBD) has not been determined yet. In this review article we summarize technical aspects and short term results of SPLS resections in patients with Crohn's disease or ulcerative colitis. Methods. A systematic review of the literature until January 2012 was performed. Publications were assessed for operative techniques, equipment, surgical results, hospital stay, and readmissions. Results. 34 articles, published between 2010 and 2012, were identified reporting on 301 patients with IBD that underwent surgical treatment in SPLS technique. Surgical procedures included ileocolic resections, sigmoid resections, colectomies with end ileostomy or ileorectal anastomosis, and restorative proctocolectomies with ileum-pouch reconstruction. There was a wide variety in the surgical technique and the employed equipment. The overall complication profile was similar to reports on standard laparoscopic surgery in IBD. Conclusions. In experienced hands, single port laparoscopic surgery appears to be feasible and safe for the surgical treatment of selected patients with IBD. However, evidence from prospective randomized trials is required in order to clarify whether there is a further benefit apart from the avoidance of additional trocar incisions.
doi:10.1155/2012/106878
PMCID: PMC3350982  PMID: 22619710
19.  Laparoscopic versus open surgery for the treatment of colorectal cancer: a literature review and recommendations from the Comité de l’évolution des pratiques en oncologie 
Canadian Journal of Surgery  2013;56(5):297-310.
Background
Adoption of the laparoscopic approach for colorectal cancer treatment has been slow owing to initial case study results suggesting high recurrence rates at port sites. The use of laparoscopic surgery for colorectal cancer still raises a number of concerns, particularly with the technique’s complexity, learning curve and longer duration. After exploring the scientific literature comparing open and laparoscopic surgery for the treatment of colorectal cancer with respect to oncologic efficacy and short-term outcomes, the Comité de l’évolution des pratiques en oncologie (CEPO) made recommendations for surgical practice in Quebec.
Methods
Scientific literature published from January 1995 to April 2012 was reviewed. Phase III clinical trials and meta-analyses were included.
Results
Sixteen randomized trials and 10 meta-analyses were retrieved. Analysis of the literature confirmed that for curative treatment of colorectal cancer, laparoscopy is not inferior to open surgery with respect to survival and recurrence rates. Moreover, laparoscopic surgery provides short-term advantages, including a shorter hospital stay, reduced analgesic use and faster recovery of intestinal function. However, this approach does require a longer operative time.
Conclusion
Considering the evidence, the CEPO recommends that laparoscopic resection be considered an option for the curative treatment of colon and rectal cancer; that decisions regarding surgical approach take into consideration surgeon experience, tumour stage, potential contraindications and patient expectations; and that laparoscopic resection for rectal cancer be performed only by appropriately trained surgeons who perform a sufficient volume annually to maintain competence.
doi:10.1503/cjs.005512
PMCID: PMC3788008  PMID: 24067514
20.  EnROL: A multicentre randomised trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme 
BMC Cancer  2012;12:181.
Background
During the last two decades the use of laparoscopic resection and a multimodal approach known as an enhanced recovery programme, have been major changes in colorectal perioperative care. Clinical outcome improves using laparoscopic surgery to resect colorectal cancer but until recently no multicentre trial evidence had been reported regarding whether the benefits of laparoscopy still exist when open surgery is optimized within an enhanced recovery programme. The EnROL trial (Enhanced Recovery Open versus Laparoscopic) examines the hypothesis that laparoscopic surgery within an enhanced recovery programme will provide superior postoperative outcomes when compared to conventional open resection of colorectal cancer within the same programme.
Methods/design
EnROL is a phase III, multicentre, randomised trial of laparoscopic versus open resection of colon and rectal cancer with blinding of patients and outcome observers to the treatment allocation for the first 7 days post-operatively, or until discharge if earlier. 202 patients will be recruited at approximately 12 UK hospitals and randomised using minimization at a central computer system in a 1:1 ratio. Recruiting surgeons will previously have performed >100 laparoscopic colorectal resections and >50 open total mesorectal excisions to minimize conversion. Eligible patients are those suitable for elective resection using either technique. Excluded patients include: those with acute intestinal obstruction and patients in whom conversion from laparoscopic to open procedure is likely. The primary outcome is physical fatigue as measured by the physical fatigue domain of the multidimensional fatigue inventory 20 (MFI-20) with secondary outcomes including postoperative hospital stay; complications; reoperation and readmission; quality of life indicators; cosmetic assessments; standardized performance indicators; health economic analysis; the other four domains of the MFI-20. Pathological assessment of surgical quality will also be undertaken and compliance with the enhanced recovery programme will be recorded for all patients.
Discussion
Should this trial demonstrate that laparoscopic surgery confers a significant clinical and/or health economic benefit this will further support the transition to this type of surgery, with implications for the training of surgeons and resource allocation.
Trial registration
ISRCTN48516968.
doi:10.1186/1471-2407-12-181
PMCID: PMC3441229  PMID: 22591460
Laparoscopy; Colon cancer; Rectal cancer; Enhanced recovery programme; Fast track surgery; Health economics; Cosmetic assessment; Fatigue; Randomised controlled trial; EnROL
21.  Expert Opinion on Laparoscopic Surgery for Colorectal Cancer Parallels Evidence from a Cumulative Meta-Analysis of Randomized Controlled Trials 
PLoS ONE  2012;7(4):e35292.
Background
This study sought to synthesize survival outcomes from trials of laparoscopic and open colorectal cancer surgery, and to determine whether expert acceptance of this technology in the literature has parallel cumulative survival evidence.
Study Design
A systematic review of randomized trials was conducted. The primary outcome was survival, and meta-analysis of time-to-event data was conducted. Expert opinion in the literature (published reviews, guidelines, and textbook chapters) on the acceptability of laparoscopic colorectal cancer was graded using a 7-point scale. Pooled survival data were correlated in time with accumulating expert opinion scores.
Results
A total of 5,800 citations were screened. Of these, 39 publications pertaining to 23 individual trials were retained. As well, 414 reviews were included (28 guidelines, 30 textbook chapters, 20 systematic reviews, 336 narrative reviews). In total, 5,782 patients were randomized to laparoscopic (n = 3,031) and open (n = 2,751) colorectal surgery. Survival data were presented in 16 publications. Laparoscopic surgery was not inferior to open surgery in terms of overall survival (HR = 0.94, 95% CI 0.80, 1.09). Expert opinion in the literature pertaining to the oncologic acceptability of laparoscopic surgery for colon cancer correlated most closely with the publication of large RCTs in 2002–2004. Although increasingly accepted since 2006, laparoscopic surgery for rectal cancer remained controversial.
Conclusions
Laparoscopic surgery for colon cancer is non-inferior to open surgery in terms of overall survival, and has been so since 2004. The majority expert opinion in the literature has considered these two techniques to be equivalent since 2002–2004. Laparoscopic surgery for rectal cancer has been increasingly accepted since 2006, but remains controversial. Knowledge translation efforts in this field appear to have paralleled the accumulation of clinical trial evidence.
doi:10.1371/journal.pone.0035292
PMCID: PMC3332109  PMID: 22532846
22.  Single-incision laparoscopic colectomy without using special articulating instruments: an initial experience 
Background
Single-incision laparoscopic colectomy (SILC) was introduced as a novel minimally invasive technique. The benefits of this technique include reducing number of the incision and cosmetic improvement. Unlike the conventional laparoscopic colectomy, majority of previously reported SILC need to be performed using special curved or articulated instruments. The purpose of this study is to demonstrate our initial experience of SILC, which could be performed using the standard laparoscopic instruments.
Material and methods
Retrospective review of 14 patients who underwent SILC at Siriraj Hospital from May to December 2010, patient's demographic data, perioperative outcomes, early postoperative complications and pathological data were collected and analyzed.
Results
The mean age of all patients was 60 years. The most common operation with SILC was sigmoidectomy (n = 9), followed by right hemicolectomy (n = 2), left hemicolectomy (n = 1), anterior resection (n = 1), and total colectomy (n = 1). The trocar insertion techniques were multi-fascial incision using regular port (n = 11) and GelPOINT® (n = 3). The mean operative time was 155 minutes (range 90-280) and the mean estimate blood loss was 32.1 mL (range 10-100). All patients were successfully operated without conversion. The mean length of hospital stay was 9 days (range 5-20). There was no mortality. The pathological results revealed colorectal cancer (n = 12), neoplastic polyp (n = 1) and Familial adenomatous polyposis (FAP) (n = 1). The mean number of lymph nodes retrieval was 16.6 (range 3-34).
Conclusion
SILC can successfully and safely be performed with standard laparoscopic instruments. This technique might be an alternative procedure to conventional laparoscopic colectomy with better cosmetic result.
doi:10.1186/1477-7819-9-162
PMCID: PMC3262762  PMID: 22151649
Minimally invasive surgery; Single-incision laparoscopic colectomy; Laparoscopic colectomy; Colorectal neoplasms
23.  Does case selection and outcome following laparoscopic colorectal resection change after initial learning curve? Analysis of 235 consecutive elective laparoscopic colorectal resections 
INTRODUCTION:
Laparoscopic colorectal surgery is being widely practiced with an excellent short-term and equal long-term results for colorectal diseases including cancer. However, it is widely believed that as the experience of the surgeon/unit improves the results get better. This study aims to assess the pattern of case selection and short-term results of laparoscopic colorectal surgery in a high volume centre in two different time frames.
MATERIALS AND METHODS:
This study was done from the prospective data of 265 elective laparoscopic colorectal resections performed in a single unit from December 2005 to April 2011. The group was subdivided into initial 132 patients (Group 1) from December 2005 to December 2008 and next 133 patients (Group 2) between December 2008 and April 2011 who underwent laparoscopic colorectal resections for cancer. The groups were compared for intraoperative and perioperative parameters, type of surgery, and the stage of the disease.
RESULTS:
The age of patients was similar in Groups 1 and 2 (57.7 and 56.9, respectively). Patients with co-morbid illness were significantly more in Group 2 than in Group 1 (63.2% vs. 32.5%, respectively, P≤0.001). There were significantly more cases of right colonic cancers in Group 1 than in Group 2 (21.9% vs. 11.3%, respectively, P<0.02) and less number of low rectal lesions (20.4% vs. 33.8%, respectively, P≤0.02). The conversion rates were 3.7% and 2.2% in Groups 1 and 2, respectively. The operating time and blood loss were significantly more in Group 1 than in Group 2. The ICU stay was significantly different in Groups 1 and 2 (31.2± 19.1 vs. 24.7± 18.7 h, P≤0.005). The time for removal of the nasogastric tube was significantly earlier (P=0.005) in Group 2 compared to Group 1 (1.37± 1.1 vs. 2.63±1.01 days). The time to pass first flatus, resumption of oral liquids, semisolid diet, and complications were similar in both groups. The hospital stay was more in Group 1 than in Group 2 ( P≤0.01). The numbers of lymph nodes retrieved was similar in both groups. The T stage of the disease in Groups 1 and 2 were similar, however, the number of T4 lesions was significantly more in Group 2 (8.3% vs. 18.7%, respectively, P<0.01).
CONCLUSION:
This study shows that with increasing experience, laparoscopic colorectal surgery can be practiced safely with minimal conversion rates and morbidity. As the units experience improves, there is a trend towards selecting advanced cases and performing complex laparoscopic colorectal procedures. With increasing experience, there is a trend towards better short-term outcome after laparoscopic colorectal surgeries.
doi:10.4103/0972-9941.115366
PMCID: PMC3764663  PMID: 24019686
Case selection; laparoscopic colectomy; learning curve; short-term results
24.  Laparoscopic liver resection: Current role and limitations 
Laparoscopic liver resection (LLR) for the treatment of benign and malignant liver lesions is often performed at specialized centers. Technological advances, such as laparoscopic ultrasonography and electrosurgical tools, have afforded surgeons simultaneous improvements in surgical technique. The utilization of minimally invasive techniques for liver resection has been reported to reduce operative time, decrease blood loss, and shorten length of hospital stay with equivalent postoperative mortality and morbidity rates compared to open liver resection (OLR). Non-anatomic liver resection and left lateral sectionectomy are now routinely performed laparoscopically at many institutions. Furthermore, major hepatic resections are performed by pure laparoscopy, hand-assisted technique, and the hybrid method. In addition, robotic surgery and single port surgery are revealing early promising results. The consensus recommendation for the treatment of benign liver disease and malignant lesions remains unchanged when considering a laparoscopic approach, except when comorbidities and anatomic limitations of the liver lesion preclude this technique. Disease free and survival rates after LLR for hepatocellular carcinoma and metastatic colon cancer correspond to OLR. Patient selection is a significant factor for these favorable outcomes. The limitations include LLR of superior and posterior liver lesions; however, adjustments in technique may now consider a laparoscopic approach as a viable option. As growing data continue to reveal the feasibility and efficacy of laparoscopic liver surgery, this skill is increasingly being adopted by hepatobiliary surgeons. Although the full scope of laparoscopic liver surgery remains infrequently used by many general surgeons, this technique will become a standard in the treatment of liver diseases as studies continue to show favorable outcomes.
doi:10.4251/wjgo.v4.i8.187
PMCID: PMC3423509  PMID: 22912914
Laparoscopic liver resection; Laparoscopic hepatectomy; Minimally invasive liver surgery; Hand-assisted technique; Hybrid technique
25.  Laparoscopic vs. open approach for colorectal cancer: evolution over time of minimal invasive surgery 
BMC Surgery  2013;13(Suppl 2):S12.
Background
In the late '80s the successes of the laparoscopic surgery for gallbladder disease laid the foundations on the modern use of this surgical technique in a variety of diseases. In the last 20 years, laparoscopic colorectal surgery had become a popular treatment option for colorectal cancer patients.
Discussion
Many studies emphasized on the benefits stating the significant advantages of the laparoscopic approach compared with the open surgery of reduced blood loss, early return of intestinal motility, lower overall morbidity, and shorter duration of hospital stay, leading to a general agreement on laparoscopic surgery as an alternative to conventional open surgery for colon cancer. The reduced hospital stay may also decrease the cost of the laparoscopic surgery for colorectal cancer, despite th higher operative spending compared with open surgery. The average reduction in total direct costs is difficult to define due to the increasing cost over time, making challenging the comparisons between studies conducted during a time range of more than 10 years. However, despite the theoretical advantages of laparoscopic surgery, it is still not considered the standard treatment for colorectal cancer patients due to technical limitations or the characteristics of the patients that may affect short and long term outcomes.
Conclusions
The laparoscopic approach to colectomy is slowly gaining acceptance for the management of colorectal pathology. Laparoscopic surgery for colon cancer demonstrates better short-term outcome, oncologic safety, and equivalent long-term outcome of open surgery. For rectal cancer, laparoscopic technique can be more complex depending on the tumor location. The advantages of minimally invasive surgery may translate better care quality for oncological patients and lead to increased cost saving through the introduction of active enhanced recovery programs which are likely cost-effective from the perspective of the hospital health-care providers.
doi:10.1186/1471-2482-13-S2-S12
PMCID: PMC3851244  PMID: 24267544

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