Surg Endosc (2013) 27:2613–2618 DOI 10.1007/s00464-013-2799-5
and Other Interventional Techniques
Totally laparoscopic versus laparoscopic-assisted right colectomy for colon cancer: is there any advantage in short-term outcomes? A prospective comparative assessment in our center Carmelo Magistro • Stefano Di Lernia • Giovanni Ferrari • Antonio Zullino • Michele Mazzola • Paolo De Martini • Stefano De Carli • Antonello Forgione • Camillo Leonardo Bertoglio • Raffaele Pugliese
Received: 18 August 2012 / Accepted: 28 December 2012 / Published online: 9 February 2013 Ó Springer Science+Business Media New York 2013
Abstract Background Several techniques are described in the literature about laparoscopic treatment of the right colon. Among them, laparoscopic-assisted colectomy (LAC) with creation of an extracorporeal ileocolonic anastomosis remains the favourite approach in most centers. So far, total laparoscopic colectomy (TLC) with intracorporeal anastomosis is not widely performed, because it requires adequate skills and competence in the use of mechanical linear staplers and laparoscopic manual sutures. The purpose of this study was to determine prospectively if TLC offers some advantages in short-term outcomes over LAC. Methods A prospective comparative study was designed for 80 consecutive patients who were alternatively treated with TLC and LAC for right colon neoplasms. The following data were collected: operative time, intra- and postoperative complication rate, time to bowel movement, hospitalization time, length of minilaparotomy, number of harvested lymph nodes, and specimen length. Results Operative time in TLC resulted significantly longer than in LAC (230 vs. 203 min), complication rate was similar in both groups, with no case of anastomotic dehiscence, two anastomotic bleedings in TLC vs. three in
C. Magistro (&) S. D. Lernia G. Ferrari P. De Martini S. De Carli A. Forgione C. L. Bertoglio R. Pugliese Chirurgia Generale Oncologica e Mininvasiva, Ospedale Niguarda Ca` Granda, Milan, Italy e-mail:
[email protected] A. Zullino Chirurgia Generale ‘‘F. Durante’’, Policlinico Umberto I (Universita` Sapienza), Rome, Italy M. Mazzola Universita` degli Studi di Milano, Milan, Italy
LAC and one case of postoperative ileus for each group. One case of death occurred in LAC patient developing a postoperative severe cardiopulmonary syndrome. Time to first flatus was in favour of TLC (2.2 vs. 2.6 days), whereas hospitalization was comparable. As regards to the oncological parameters of radicality, the specimen length was superior in TLC group, but the number of lymph nodes excised was equivalent. The length of the minilaparotomy was clearly shorter in TLC group (5.5 vs. 7.2 cm). Conclusions No evidence of relevant differences in terms of functional and safety outcomes between the two laparoscopic procedures. TLC determines less abdominal manipulation and shorter incision length, but clear advantages must be still demonstrated. Larger series are necessary to test the superiority of totally laparoscopic procedures for right colectomy. Keywords Laparoscopic right colectomy Total laparoscopic colectomy Right colectomy Extracorporeal anastomosis Intracorporeal anastomotic
Today, the laparoscopic approach is accepted and increasingly performed for the treatment of benign and malignant colorectal disease, having demonstrated its feasibility in terms of safety and oncologic radicality [1–5]. Furthermore, several studies have definitively confirmed the superiority of the laparoscopic approach over the traditional open colectomy for quicker return of bowel function, smaller incisions with less postoperative pain and better aesthetics, less pulmonary complications, and shorter hospital stay [5–10]. In the framework of laparoscopic colorectal surgery, right colectomy becomes one of the most technically difficult procedures when an intracorporeal anastomosis (totally laparoscopic colectomy [TLC]) has to be
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performed [11]. The wider range of bowel resection and the anatomic variability of the vascular architecture represent the crucial aspects to take into account when performing this intervention. Moreover, the necessity of performing an intracorporeal anastomosis using mechanical linear staplers together with the need of laparoscopic manual sutures, undoubtedly adds an increased level of difficulty to perform such kind of operation [12]. This could explain the slower diffusion of right TLC and why the most colorectal referral centers have not yet adopted this kind of anastomotic technique as current standard. During the past two decades, in our Department of General Minimally Invasive and Oncological Surgery, we have performed an average of 180 laparoscopic interventions per year for colorectal disease; moreover, we already experienced the feasibility and the safety of the right TLC for neoplastic disease, performing approximately 30 of these interventions between June 2007 and December 2008. The purpose of this prospective study, nonrandomized, non-case-matched was to compare our short-term postoperative results obtained in two homogeneous groups of patients, respectively undergone to TLC and to laparoscopic right colectomy with extracorporeal anastomosis (laparoscopic-assisted colectomy, LAC) during the same period. We hypothesized that TLC can guarantee some benefits over LAC in short-term outcomes. Materials and methods Patients From January 2009 to September 2011, 132 patients underwent right colectomy at our center, 80 of them with laparoscopic approach. Instead, 52 patients were treated with conventional open technique, 4 starting with laparoscopic approach and converted into open surgery, and 48 not eligible for laparoscopic surgery: –
–
–
–
Seventeen patients with locally advanced disease (T4 disease and/or lymphadenopathy extended to the origin of mesenteric vessels, to the subpyloric region or to the peripancreatic region); Thirteen patients programmed for an associated major intervention (hepatic resections for colon cancer metastases or multiple colonic resections for synchronic lesions); Nine patients with surgical contraindication (patients with a history of major abdominal surgery or previous unsuccessful laparoscopy and patients with bowel obstruction); Nine patients with anesthesiologist contraindication to laparoscopy, for cardiovascular and/or respiratory comorbidities.
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On that account, 80 consecutive patients were enrolled in our study and were alternatively assigned, at the moment of hospitalization, to both treatment groups, independently of their starting clinical condition. In 40 patients we performed the intervention with an extracorporeal mechanical ileocolic anastomosis (group LAC) and in the other 40 patients we executed a totally laparoscopic colectomy, with an intracorporeal anastomosis (group TLC). The two groups were compared in terms of demographic characteristics, preoperative general status, disease factors, and surgical outcomes. The following data were collected and analyzed: age, gender, body mass index (BMI), American Society of Anaesthesiologists (ASA) class, history of previous abdominal operations, localization and stage of the colonic lesion, operation time, intra- and postoperative complication rate, time to bowel movement (to flatus and to stool), length of hospital stay, length of minilaparotomy, and oncological parameters of surgical radicality. Our first end point was to compare LAC and TLC groups in terms of intra- and postoperative short-term outcomes. Our second end point was the histological evaluation in LAC and TLC groups with regards to specimen length and number of excised lymph nodes. Surgical technique Two surgical techniques were performed and compared: LAC and TLC. In both approaches open laparoscopy using Hasson’s trocar was performed. The Veress needle technique was a practiced alternative to the classic open-laparoscopy to create pneumoperitoneum and four ports in total are generally used. The placement of the first three trocars was the same in both approaches: two 12-mm ports are inserted in the left abdominal wall along the pararectal line (symmetrically, one below for a 30° camera and the other above the umbilicus) and a 10-mm port in median suprapubic position. A 5-mm assistant port was placed in the right hypochondrium for LAC and under xiphoid on the left of the middle line for TLC. In LAC, a first step consisted in the exposure of vascular pedicles of ileocolic trunk and right colic trunk; a second step consisted in complete mobilization of the right colon and of the last ileal trait (performed in medial-to-lateral fashion, using Cattel-Braasch manoeuvre); then the bowel was externalized via a mini-incision on the trocar site in the right hypochondrium. Finally, the right trunk of medium colic pedicle was ligated at the origin and bowel was resected using a linear stapler with final side-to-side mechanic anastomosis. Sometimes right trunk of medium colic pedicle could be legated intracorporeally. In TLC, all the steps were executed intracorporeally and the operative specimen, previously allocated into a plastic bag, was extracted via a mini Pfannenstiel incision on the site of the
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suprapubic trocar. A side-to-side isoperistaltic mechanical anastomosis with a double-layered continuous suture closing the enterotomies practised for the introduction of the stapler was performed in both techniques, intracorporeal in TLC, extracorporeal in LAC. In both approaches, no abdominal drain was routinely inserted. Perioperative management Preoperative bowel preparation was routinely performed with sennosides solution (X-Prep), two doses and one dose of 75 ml respectively 4 and 3 days before operation, in association with a fiber-free diet (except for those enrolled in fast-track protocol). Patient was admitted in the afternoon of the day before the procedure. Deep venous prophylaxis with low-molecular-weight heparin (4,000 IU) was started the evening before operation and continued until postoperative day (POD) 30. Antibiotic prophylaxis with 2 g of cefazolin and 500 mg of metronidazole was administered before the anesthetic induction and then repeated 8 and 16 hours after the operation. Nasogastric tube was inserted on demand during the operation and always removed at the end in absence of need. Urinary catheter was generally removed at the end of POD 1. Spinal anesthesia with bupivacaine (0.5 % hyperbaric Marcaine, 10 mg) ? morphine 0.2–0.3 mg was always associated with general anesthesia. Intraoperative infusion of liquids was at 10 ml/kg/h during all the intervention. Statistical analysis Statistical analysis was calculated using software SPSS for Windows (version 13.0). Pearson v2 (or Fisher exact test) and Student’s t test were used to test for significance, respectively in categorical and quantitative variables. p \ 0.05 was considered to represent statistical significance for all comparisons.
Results There was no statistical difference between the two groups in terms of demographics, preoperative physical status (ASA), history of previous abdominal surgery, localization and stage of disease (Table 1). Among the examined surgical outcomes, we found a statistically significant difference between the two techniques for the following parameters (Table 2): operative time, length of the incision for specimen extraction, surgical specimen length and time to first flatus. Operative time was shorter in LAC than in TLC group. The length of skin incision for the specimen extraction, the specimen length and timing to first flatus were in favor of the TLC
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group. No differences were registered for postoperative complications: we had no case of anastomotic leak but five cases in a total of 80 patients (incidence rate = 6.25 %) of anastomotic bleeding: two needed endoscopic treatment and three spontaneously resolved. A retroperitoneal haematoma was found at CT abdomen in a patient of the TLC group, with hemoglobin loss of 2 g/dL on POD 2, needing longer postoperative observation. The two cases of transient ileus were solved with nasogastric tube reinsertion. There was one case of postoperative death (on POD 6), in a patient with bilateral pleural effusion on POD 4 at the origin of a severe cardiopulmonary syndrome. In regards to nonsurgical complications, we had one case of pneumonia treated with antibiotics, one case of transient mental confusion in an old patient, and one patient discharged later for lipothymic episode. There was no readmission to the hospital. With regard to the extraction-site location, in TLC it was routinely a transversal Pfannenstiel incision realized on the suprapubic trocar site. In LAC, all patients received a right subcostal minilaparotomy on the hypochondrium trocar site, except for two patients with a pre-existing midline scar who received a shorter midline supraumbilical incision.
Discussion From the end of 1998 to the first half of 2007, in our Department of General Surgery, we exclusively performed LAC for the laparoscopic treatment of benign and malignant right colon lesions. In June 2007, we realized our first right TLC, and the vessels ligation, colon mobilization and resection, and the creation of the anastomosis were all completely intracorporeally executed. We think that TLC represents an improvement in the surgical treatment of right colon diseases, feasible with safety and reproducibility after an adequate learning period in using mechanical linear staplers and performing laparoscopic manual sutures. Our training was not particularly hard, also considering that TLC repeats the same surgical steps of LAC until the time of ileum and colon resection and that the two techniques only differ in the way of performing the ileocolic anastomosis. Although its advantage on the other laparoscopy-assisted procedures is far from being demonstrated, we have postulated the following theoretic advantages: (a) direct manipulation of the bowel trait harboring the lesion is minimized; (b) being an entirely intracorporeal procedure, the mesenteric tractions are decreased compared with laparoscopic-assisted techniques and the risk of anastomotic twist may be lower; (c) the bowel does not come in contact with the outside, expecting less microbial contaminations.
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Table 1 Patients demographics and disease factors
TLC (n = 40 patients)
LAC (n = 40 patients)
p value
Age (yr)
70.9 ± 13.4 (30–91)
71.2 ± 10.5 (41–86)
0.911 (NS)
Male/female ratio
20/20
18/22
0.654 (NS)
BMI (Kg/m2)
24.8 ± 2.8
23.9 ± 4.4
0.317 (NS)
ASA 1/2/3
3/29/8
4/26/10
0.768 (NS)
Previous abdominal surgery
13 (32.5 %)
9 (22.5 %)
0.317 (NS)
Cecum
18
20
0.876 (NS)
Ascending
13
12
Tumor localization
T0 corresponds to high-grade dysplastic lesion, Tis to in situ adenocarcinoma NS not statistically significant (p [ 0.05)
Right flexure
6
4
Proximal transverse
3
4
Stage T (0/is/T1/2/3/4)
3/0/2/9/25/1
3/8/2/6/21/0
0.077 (NS)
Stage N (N0/1/2)
25/13/2
27/8/5
0.279 (NS)
Grading (G1/2/3)
4/29/7
12/24/4
0.071 (NS)
Table 2 Short-term outcomes and histological findings Operating time (min)
TLC (n = 40 patients)
LAC (n = 40 patients)
p value
230 ± 45
203 ± 48
0.011
Intraoperative complications
0
0
-
Laparotomy conversion
0
0
-
Anastomotic dehiscence
0
0
-
Anastomotic bleeding
2
3
0.644 (NS)
Postoperative complications
Bold values indicate statistically significance (p \ 0.05) NS not statistically significant (p [ 0.05)
Wound infection
0
1
0.314 (NS)
Postoperative ileus
1
1
1.000 (NS)
Other bleedings
1
0
0.314 (NS)
Need for postoperative transfusion
2
1
0.556 (NS)
Pneumonia
0
1
0.314 (NS)
Minor morbidity
1
1
1.000 (NS)
Death
0
1
0.314 (NS)
Time to first flatus (days)
2.2 ± 0.6 (1–4)
2.6 ± 0.8 (0–4)
0.043
Time to first defecation (days) Reoperations
3.5 ± 1.1 (2–6) 0
3.8 ± 1.1 (2–6) 0
0.234 (NS) -
Hospital stay (days)
6.3 ± 3.1 (3–18)
6 ± 1.8 (3–14)
0.638 (NS)
Specimen length (cm)
37.7 ± 12
29.8 ± 8.2
0.001
Length of mini-laparotomy (cm)
5.5 ± 1.1 (4–9)
7.2 ± 1.3 (5.5–11)
0.01
Lymph nodes excised (n)
22 ± 10
20 ± 10
0.343 (NS)
Tumour-free resection margin (n)
40
40
-
Indeed, some of the advantages of TLC over LAC are the length of skin incision, the possibility of choosing the specimen extraction site, and the even easier execution in obese patients. We found significant difference in the length of skin incision in favour of TLC (p = 0.01), in agreement with other experiences reported in the literature [13–15]. However, our study lacks a patient satisfaction scale for cosmetic outcomes and postoperative pain assessment, the latter referred lower in TLC by some authors [14, 16]. Instead, one of the remarkable benefits of the intracorporeal technique is the possibility to remove the
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specimen from the more convenient incision for each patient. We usually opt for the Pfannenstiel incision, because it is reported to be associated with lower rates of incisional hernia [17–19] and better aesthetics results, but each pre-existing scar may be useful for the specimen extraction. From this point of view, natural orifice specimen extraction (NOSE), performed by some authors in colorectal surgery [20], represents further optimization, because it potentially avoids the incision-related morbidity of the minilaparotomy. Finally, TLC can be a more suitable choice compared with LAC when treating obese patients.
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In this subset of patients, it often is more difficult to exteriorize two sufficiently long limbs of bowel for the double resection and the extracorporeal anastomosis because of a thicker abdominal wall and a stouter specimen [13, 21–23]. In such cases, the surgeon often is forced to extend the specimen extraction incision significantly to perform the intervention safely. A completely laparoscopic colectomy does not meet this technical problem, avoiding the strong tractions necessary to the bowel external resection and, at the same time, a long laparotomy on the extraction site. The main controversies existing in literature concern operative times, specimen length and harvested lymph nodes, recovery of the intestinal functions, and hospital stay [13–16]. In our series, we found that the mean operative time of TLC is longer than LAC (p = 0.011), but this difference disappears when comparing the duration of the last ten consecutive interventions of both techniques. We experienced a real shortening of the operative times in TLC during our learning curve with the intracorporeal anastomosis. A sufficient oncological radicality was demonstrated by both techniques in terms of length of the bowel resected and number of lymph nodes examined. We obtained a significantly longer operative specimen in TLC group than in LAC group (p = 0.001). It may appear to be a great advantage considering that colon length is positively correlated with the number of lymph nodes sampled [24–26], with better tumor staging and prognosis independent from metastatic involvement [26, 27]. A longer extension of colon represents more mesocolon tissue where lymph nodes could be harvested. In our series, we did not find this correspondence, being insignificant the difference between TLC and LAC in terms of lymph node analyzed. Actually, because this parameter depends on a high number of variable factors (e.g., specimen length and thickness, tumor stage and location, anatomic variability of the patient, surgeon and pathologist work)—the most important being the care of the pathologist called to the histological lymph node retrieval—definitive conclusions cannot be drawn about its accuracy. Regarding the return of bowel movement, we registered an earlier time to first flatus in the TLC group (p = 0.043), but no significant difference of time to first defecation. The hospital stay was not different between the two groups, approximately 6 days. Also, the complication rate was comparable between the two techniques. The main limit of our study is the low number and the nonrandomized criterion of our patients’ enrollment, but it is significant that we have never experienced any intra- or postoperative complications due to laparoscopic anastomosis itself, in agreement with the complication rates of LAC group and those reported by other authors [13–16].
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Although the expectations seem to be encouraging and TLC has been demonstrated to be a feasible and safe procedure in our hands, further reports on larger series and randomized, controlled trials are necessary to promote TLC as the laparoscopic procedure of choice for the surgical treatment of right colon diseases. Disclosures Drs. Magistro Carmelo, Di Lernia Stefano, Ferrari Giovanni, Zullino Antonio, Mazzola Michele, De Martini Paolo, De Carli Stefano, Forgione Antonello, Bertoglio Camillo Leonardo, and Pugliese Raffaele have no conflicts of interest or financial ties to disclose.
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