The role of laparoscopy in the management of colonic polyps

Abstract

Dear Editor: The role of colonoscopy in the diagnosis of colonic polyps as well as other benign or malignant pathology is well established nowadays. Furthermore, its therapeutic intervention by various technical modalities has been in progress, gaining higher levels of reliability. Thus, the endoscopic polypectomy by snare has already become the first choice procedure, even for large colonic polyps. However, some controversy exists in cases of large (more than 3 cm in diameter) sessile polyps regarding the incomplete snare resection and the possibility of coexisting malignancy. The risk of malignant transformation correlates well with the size of the polyp, reaching up to 30% for colonic and 50% for rectal polyps. Consequently, although endoscopic snare resection of colonic polyps remains the method of choice, surgical resection should be performed in cases of inaccessible or malignantly transformed polyps. Additionally, the histopathology of the endoscopically obtained material for biopsy cannot always be helpful preoperatively, despite the malignant transformation of the polyp. The traditional open management includes either colotomy and polyp resection in pedunculated cases, limited colectomy in large sessile cases, or wide colectomy in cases of possible or confirmed malignancy. Recently, the modern laparoscopic procedure has gained a well-defined role in the management of colonic polyps. First, in some cases of large and otherwise inaccessible polyps with no malignancy, the laparoscopic-assisted colonoscopic polypectomy could be helpful by mobilizing the colon and avoiding the risk of perforation. Second, the laparoscopic colectomy could be an alternative method substituting the traditional open procedure in cases of colonoscopic failure or malignant transformation. Despite the obvious advantages of the laparoscopic approach such as minimally invasive surgery, i.e. less postoperative pain, early return of bowel function, better cosmetic result, and early return to normal activity, it has not yet gained broad acceptance. This maybe due to its inherent technical difficulties, which demand appropriate training and advanced laparoscopic skills. Also, it needs proper instrumentation and takes longer. The removed specimen can be shorter than of that of open colectomy; this is important in cases of malignant transformation, where a wide oncological resection is necessary. T. E. Pavlidis Medical School of the Aristotle University of Thessaloniki, Thessaloniki, Greece