Minimal-Invasive Chirurgie bei Dickdarmkrebs

Laparoscopic colectomy: lessons learned and future prospects

Laparoscopic colectomy, or minimally invasive surgery for colon cancer, is now considered an acceptable alternative to standard open colectomy. The COlon cancerLaparoscopic or Open Resection (COLOR) trial, reported in this month’s issue of The Lancet Oncology (1) refutes previous observations of increased rates of wound tumour implants and lays to rest the concern that laparoscopic techniques are dangerous in the setting of cancer. The level one data from this trial suggest that laparoscopic colectomy is not an inferior oncological procedure to open colectomy; it neither predisposes to surgical shortcuts nor to unique mechanisms of tumour dissemination.
This is a major step forward for laparoscopic oncological surgery and future patients should benefit from the knowledge gained from this trial.To a non-surgeon, this might seem like the end of the story. In fact, to someone not involved directly in the field, it might seem that a great deal of attention has been placed on the testing of a single new procedure (2–5). However, to reduce this story to such a simple conclusion would not do justice to the many lessons learned along the way and to how such lessons will affect the future of surgery. Consider, for example, what has been learnt about the patient’s perspective on surgery. The fact that more than 1765 patients with colon cancer have participated in laparoscopic trials has taught us a great deal about the relative importance of pain, scars, quality of life, and duration of recovery in patient decision-making (6). In order to have less postsurgical pain and discomfort, patients readily accepted the risk that laparoscopic colectomy might offer them an inferior oncological result to open colectomy. The willingness of patients to accept the tradeoff between cancer outcomes andpostoperative outcomes has encouraged surgeons tocontinue to explore new methods for further decreasing postsurgical pain.
Indeed, trials are underway to test the role of laparoscopic proctectomy in patients with rectal cancer, such as the phase III trials being run by both theCOLOR and Clinical Outcomes of Surgical Therapy (COST) groups (now part of the American College of Surgeons Oncology Group) (7). These new trials place less emphasis on concerns specific to abdominal insufflation and atypical tumour seeding and more emphasis on whether complex oncological pelvic resection of the rectum can be achieved. If the extent of resection achieved with open techniques, measured by pathological margins and rates of local relapse, can be replicated with laparoscopic techniques, further steps to achieving natural-orifice surgery might not be so distant. Indeed, some would argue that natural-orifice surgery is the logical extension of current laparoscopic and endoscopic colon and rectal surgery, because the target organ—the bowel—and the natural orifice—the anus—are continuous structures. Although the realisation of natural-orifice surgery is not expected for several years, we are substantially closer to this reality as a result of lessons learned from these laparoscopic trials in colon cancer.
From the surgeon’s perspective, we have learned that complex minimally invasive procedures can be done in diverse practices, by surgeons with diverse training, and in multinational environments. The feasibility of laparoscopic colectomy in practice is confirmed by the findings reported by the COLOR group, with perioperative death and complication rates as low as 1% and 21%, respectively (1). We might never know if these findings are due to the technical standards, credentialing processes, or the positive feedback effects of audits. What we do know, however, is that these trials and the capacity to video-record surgery has ushered in new opportunities to measure, monitor, and safely introduce new surgical procedures. Laparoscopic video recording has aided, for the first time, the ability of surgeons to witness the surgical techniques of another surgeon. Historically, it was almost prohibitive for surgeons to spend time reviewing the procedure of another surgeon at a different institution. The opportunity to review video-recorded operative details allows a new level of surgical standardisation, dialogue, and innovation. As mentioned previously, technical dialogue will certainly speed the development of the instrumentation and techniques needed to achieve natural-orifice surgery in this setting.
Lastly, the Barcelona, COLOR, Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer(CLASICC), and COST trials have assuredly dispelled the concept that randomised trials are inappropriate for surgical procedures; a long and steadfast perception (8). Arguably, it is the systematic knowledge obtained during the laparoscopic trials that has enhanced the feasibilityof complex surgery, set new surgical standards (9) and allowed a smooth and measured transition of this new technology into practice.

Heidi NelsonMayo Clinic and Foundation, Rochester, MN 55905, USAnelsonh@mayo.edu
The author declared no confl icts of interest.
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7 Soop M, Nelson H. Laparoscopic-assisted proctectomy for rectal cancer:on trial. Ann Surg Oncol 2008; 15: 2418–25.
8 Bonchek LI. Are randomized trials appropriate for evaluating new operations? N Engl J Med 1979; 301: 44–45.
9 Nelson H, Petrelli N, Carlin A, et al. Guidelines 2000 for colon and rectalsurgery. J Natl Cancer Inst 2001; 93: 583–96.

The Lancet Oncology Volume 10, Issue 1, Pages 1-96 (January 2009