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In May 2004, the New England Journal Medicine published a study which once and for all affirmed what many general surgeons have known for years: that minimally invasive techniques can be used for removal of cancers of the bowel with the same results as more old fashioned techniques*. For many years prior to this landmark study, there were doubts about several issues associated with laparoscopic colorectal cancer surgery. Questions had been circulating about the possibility of cancer implants at the site of the small incisions used for these procedures. There were concerns about the thoroughness of the cancer operation, whether adequate surgical margins around cancers could be obtained laparoscopically or whether an adequate lymph node resection was possible using minimally invasive techniques. Moreover, some had doubted the perceived benefits of the minimally invasive techniques with bowel cancer, less patient discomfort, shorter hospital stays, quicker return to normal activity, and had expressed concern about possible increased complication rates. With contributions from a number of academic institutions around the country researchers determined that laparoscopic bowel surgery for cancer was first of all safe, secondly as good as open surgery for effective removal of bowel cancer; and thirdly that the minimally invasive techniques did lead to improvements in patient satisfaction issues, such as pain level, ability to resume normal eating patterns, and earlier return to normal activities.

The reasons for these improvements in patient satisfaction lies in the use of minimally invasive techniques. In traditional large bowel surgery, the patient's abdomen is opened using a long incision, usually up and down in the midline, through which the surgeon manually manipulates the internal organs, first to expose the part of the colon to be removed, then to perform the elaborate dissections required to detach the bowel from surrounding tissues. Finally the portion to be removed is cut in two places and removed with its blood supply and lymph node drainage, and the remaining bowel is hooked back together, either by a hand-sewn technique or by the use of stapling devices, creating an anastomosis between the two open ends left behind. As a result, the patient must heal not only the internal connection but also the large incision through the abdominal wall.

In laparoscopic or minimally invasive surgery, the surgeon uses carbon dioxide gas to distend the abdomen first, then performs the internal manipulations through trocar ports, or small incisions measure 1/4 to 1/2 inch, using small tubes placed through the abdominal wall. Long handled surgical instruments are passed through these trocars as the operation is observed and controlled visually using an optical telescope, or laparoscopic, to which is connected a bright light and video equipment. The laparoscope provides magnification and allows fine control of the instruments, allowing the complex dissections to be done with far less trauma to tissues than is necessary with open techniques. It is only after all the internal dissection is complete that the surgeons then make a small incision just big enough to withdraw the part of the colon to be removed. The anastomosis can then be performed either externally or internally, depending on the part of the bowel taken out, and the patients is left with only the small incisions used for the trocar, and a short, relatively unobtrusive incision at the removal site. The result is less pain for the patient, less inflammatory response within the abdominal cavity, quicker return of normal bowel functions, and therefore, quicker recovery.

Minimally invasive colon surgery is not suitable for every patient or for every lesion in the colon, but with proper patient selection these techniques can minimize the trauma associated with these major surgical procedures, and optimize recovery for individuals who require removal of portions of the large bowel for malignant or pre-malignant tumors, or for benign conditions such as diverticulitis. As the medical profession in general, and surgeons in particular, became aware of the many advantages offered by using minimally invasive techniques, it is important that patients understand their options in the field of colon and rectal surgery, and choose a surgeon who not only offers this state of the art technique, but who has the knowledge necessary to choose the right procedure for the right patient. Experience in this highly specialized field is critically important in achieving results that justify its growing reputation as the standard of care in the surgical treatment of benign and malignant condition of the large intestine.

*Nelson, H. et al
A Comparison of Laparoscopically Assisted and Open Colectomy for Colon Cancer,
New England Journal of Medicine 350:2050-2059 May 13, 2004