Since its introduction to visceral surgery some 10 years ago, laparoscopic access has been practised in almost every surgical department. For some operations, e.g. elective cholecystectomy, in which the open access trauma is high relative to the trauma of the actual operation, open access has largely been abandoned and the preferred route is now via a number of trocars. For more complex procedures, in which the access trauma is small compared to the trauma of the operation, however, the laparoscopic technique has not received such wide acceptance. Notably, reservations persist among surgeons regarding the use of laparoscopic access for potentially curable cancer of the colon or rectum, whereas amongst the lay public, high expectations of laparoscopic techniques prevail, even for oncological operations. Many publications have indeed reported technical feasibility, rapid recovery and apparently acceptable immediate complication rates of colorectal operations performed laparoscopically, including those for cancer. Few of these reports, however, meet the strict requirements applicable to clinical research and hardly any long-term results for laparoscopically treated colorectal cancer have been reported. The public, however, is impressed and equates laparoscopic access, as opposed to open access, with a gentler procedure. These expectations are supported by randomized trials, e.g. of cholecystectomy or appendectomy, which claim to demonstrate less pain, earlier mobilization, earlier hospital discharge and return to work for patients. However, most trial designs do not stand up to critical evaluation: highly subjective parameters such as pain or tiredness can only be assessed objectively in comparative trials, when the patient (and preferably also the evaluating doctor) is blinded as to the actual treatment received. If patients are aware of the access route, open or laparoscopically, their personal expectations are likely to influence the results of the trials. For example, imagine a randomized comparison of analgesic treatment, in which the patient is fully aware of whether he has received the potential pain-killer or the placebo. It is not entirely surprising, therefore, that the only randomized trial performed, one in which neither patients nor examiners were aware of whether laparoscopic or open cholecystectomy had been performed, did not confirm the purported advantages of laparoscopic surgery. Both open and laparoscopically treated patients started oral diet on the same day, were discharged on the same day and resumed full physical activity after 3 weeks. Laparoscopically treated patients, however, returned to work later than patients who had undergone open cholecystectomy/ Similarly strict protocols have not been implemented for colorectal operations. In all randomized studies reported to date, patients were aware of the route of access. Although no differences were recorded regarding postoperative ileus,- start of oral diet, 2 pulmonary function 3 or postoperative fatigue 3 after open or laparoscopic operations for colorectal cancer, laparoscopically treated patients were discharged 3 days earlier 34 and reported less pain) Again the expectations of patients could have introduced bias and we cannot be certain that laparoscopic colorectal resections are indeed much gentler than the open operation. It can be concluded, however, that laparoscopically performed colorectal surgery takes significantly longer than conventional colorectal resections, because the laparoscopic access restricts operative manipulations. It is, therefore, not surprising that randomized trials have determined higher complication rates for laparoscopic colorectal operations. 2~ Specific complications, such as removal of the wrong bowel segment or bowel injury by trocars or cautery (also euphemized as 'enterotomy'), have become apparent which are rarely encountered during open access operations for colorectal cancer. As a consequence of this, many surgeons routinely perform additional pre-operative diagnostic or therapeutic procedures to avoid these specific complications and reduce the conversion rate? These procedures include routine placement of ureteric stents, 5 contrast enema in addition to colonoscopy, 6 routine intraoperative colonoscopy 6 and preoperative computed tomography in all colon cancers to exclude local infiltration) .~ It stands to reason that these procedures are inconvenient for the patient and are expensive.
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Jun 17, 2018
Jeffrey Netto + 15
Open Access