Laparoscopic colorectal cancer surgery: panacea, placebo or just good fun?

Abstract

The timely collision of technological development of miniature video cameras, on-screen display and surgical opportunities led to the emergence of minimally invasive surgery, which has been met with open arms by surgeons and patients alike. Ever since the first laparoscopic cholecystectomy in 1987, the surgical world has been fascinated with broadening the potential indications for laparoscopic surgery. In the early 1990s, laparoscopic colorectal surgery was an emerging technique with unproven outcomes. Case reports documenting port site tumor recurrence raised concerns in the medical community, questioning the oncological outcomes and potential sacrifices that were being made in order to perform the resection in a minimally invasive manner. The initially steep learning curve and evolving technology meant longer operating times and higher costs compared with open surgery, with perhaps minimal gains in terms of length of stay, opiate use and return of bowel function. Early adapters looked for the potential advantages of laparoscopic surgery and continued to refine techniques, thus reducing operat ing times and subsequent associated costs. However, issues still remain as surgeons moved from ‘what can we do?’ to ‘what should we do?’; the question arose as to whether laparoscopic colectomy could achieve an oncologically sound resection with an equivalent extent of dissection and lymph node yield without creating new patterns of disease recurrence. It has taken almost 20 years from the initial trial designs to publication of the longterm results to clarify this. There are four landmark trials that have helped map the path forward. Interestingly, none of these trials were designed to determine whether or not laparoscopic surgery was superior to open surgery.