Michael Choti, M.D., Associate Professor of Surgery and Oncology at Johns Hopkins and Director of the Johns Hopkins Colorectal Cancer Center discusses the risks and benefits of laparoscopic colon cancer surgery.
Laparoscopic surgery, a minimally invasive procedure that requires only a few small incisions, can reduce the trauma associated with conventional surgery. Over the last decade or so, this technique has been readily adopted to treat various conditions, and today more than 95% of diseased gallbladders are removed laparoscopically.
Using laparoscopic surgery to treat colon cancer was first proposed in the early 1990s, but many surgeons were concerned they might not be able to adequately remove the colon cancer tumor using this approach. In addition, a few early reports suggested that laparoscopic surgery for colon cancer was associated with a higher rate of tumor recurrence at incision sites.
Several major trials were launched to address these concerns before the laparoscopic colon cancer surgery came into widespread use. The results of these studies are now in, and they are generally reassuring. Laparoscopic surgery for colon cancer appears to be as safe and effective as conventional “open” surgery for colon cancer, and it offers some -- albeit not very dramatic -- advantages. “What is pretty evident from these studies is that laparoscopic surgery does not compromise the effectiveness of the colon cancer operation. Yet, although the laparoscopic approach had no major downside, the upside was not great,” notes Michael Choti, M.D., Associate Professor of Surgery and Oncology at Johns Hopkins and Director of the Johns Hopkins Colorectal Cancer Center. “The bottom line is that laparoscopic surgery is another option for treating colon cancer. I present my patients with the pros and cons of the two procedures in a balanced way and let them make the choice.”
Conventional vs. Keyhole Surgery for Colon Cancer
An estimated 145,000 Americans were diagnosed with colon cancer in 2005, and about 90% of these colon cancer patients faced the prospect of surgery for complete or partial removal of their colon. In traditional open surgery, the surgeon makes an incision through the abdominal wall and then removes the tumor, a length of normal colon on either side of the cancer, and the surrounding lymph nodes. The length of the incision in traditional colon cancer surgery usually ranges from 4 to 8 inches.
Laparoscopic surgery for colon cancer typically involves the creation of three small (about 1/2 inch) incisions through which a small video camera and specially designed thin surgical instruments are inserted into the abdomen. Magnified images of the internal organs are displayed on a television monitor in the operating room. Once the colon cancer tumor is clearly visualized, the surgeon enlarges an incision to bring the colon out of the abdomen and cuts away the portion containing the cancer. The two healthy parts of the colon are then reconnected, and the colon is placed back inside the abdomen.
Although laparoscopic surgery is often referred to as keyhole surgery, this is actually a misnomer when applied to the colon cancer operation, notes Dr. Choti. “Surgeons can take out a gallbladder through a 1/2-inch keyhole incision, but we have to make an incision of three inches or so to take out a colon cancer tumor. In addition, some laparoscopic surgeons are using a ‘hand-assisted’ technique, in which the incision length may be similar to that of open surgery. Although this method may have advantages and offers a compromise between open and laparoscopic surgery, there are no studies supporting this technique.”
What the research on laparoscopic colon cancer surgery shows
Laparoscopic surgery for colon cancer has now been evaluated in three major randomized trials involving more than 2,900 patients, and the results have been reported over the last two years. In a 2004 study published in The New England Journal of Medicine (NEJM), researchers found that the three-year survival rate for patients who underwent laparoscopic surgery for colon cancer was 86%, compared with 85% for those treated with conventional surgery. Also, the rate of tumor recurrence in surgical wounds— one of the primary concerns with laparoscopic surgery—was low and did not differ between the two groups in any of the major trials.
The studies did note some advantages of laparoscopic surgery for colon cancer, such as less blood loss, less postoperative pain, reduced need for intravenous narcotics, more rapid recovery of normal bowel function, and a shorter hospital stay. For example, for patients treated laparoscopically in the NEJM study, the average length of hospitalization dropped from six to five days and the duration of intravenous narcotics decreased from four to three days.
The major drawback of laparoscopic colon cancer surgery was that it took longer to perform—ranging from 30 to 55 minutes longer than open surgery. In addition, a certain percentage of patients—ranging from 17% to 29% in the three studies—had to be switched from laparoscopic to open surgery when the surgeons found that the colon cancer had spread or they encountered other problems that made it difficult to perform the procedure laparoscopically. And those who had their operations converted experienced the most complications.
Patients who have rectal cancer are more likely to require conversion to open surgery, according to a 2005 study in The Lancet, and may not be good candidates for laparoscopic surgery. Also, patients who have had previous abdominal surgery or have bulky tumors may not be ideal candidates for this approach.
Bottom-line advice on laparoscopic colon cancer surgery
If you have recently been diagnosed with colon cancer, you may want to discuss the possibility of laparoscopic surgery with your surgeon. Dr. Choti advises, “If you have colon cancer and choose to have your operation done laparoscopically, you need to go to a surgeon who is experienced using this technique. Regardless of the specific method used to remove the colon cancer, however, it is important to seek care from an experienced surgeon who is part of a multidisciplinary team.”
