Laparoscopic or minimally invasive surgery has taken the world by storm as it is now possible to do complex operations without making a large incision. In any surgery, one is always trying to minimize the trauma of access as this merely adds to the discomfort of the operation, increased complications without conferring any benefits. Advances in surgical technique and new instrument technology has made it possible to perform many procedures safely through a laparoscope.
Open surgery - long midline scar
Laparoscopic surgery - 4 cm scar
In the past 10 years, Laparoscopic Colorectal Surgery (LCS) has gained wide acceptance moved from being merely a novel technique to becoming the standard of care for many colorectal diseases - especially inflammatory bowel and diverticular disease. There were initial doubts about it's safety in cancer, and whether the technique altered the behavior of cancer cells and the long term outcome for patients. Recent randomized trials in the US and Europe have demonstrated the safety and efficacy of laparoscopic surgery for cancer patients.
The main advantages of this technique are:
- Quicker recovery from the operation
- Early return of bowel function
- Less pain and decreased use of analgesics
- Shorter hospital stay
- Faster return to normal activities
- Better cosmesis
- Decreased wound infection
- Lower incidence of incisional hernia
- Possible improvement in cancer free survival for node positive patients
How is Laparoscopic Colorectal Surgery Performed?
Several small (5-10mm) incisions are made in the abdominal wall, and little tubes called trocars are inserted which provide channels for instruments to be introduced into the abdominal cavity. A telescope and special instruments are inserted through these trocars and the colon is dissected. One of the trocar sites is usually enlarged to enable retrieval of the resected colon.
Unlike Laparoscopic Cholecystectomy, Laparoscopic Colorectal Surgery is very demanding technically and requires considerable training and experience before the surgeon becomes reasonably competent. Several studies have indicated that one needs to do at least 20 such procedures to achieve basic competence and surgeons who had performed more than 70 laparoscopic colorectal operations had significantly better outcomes than those with lesser experience.
The procedure generally takes longer than conventional surgery, and special instruments may be required to enable to surgeon to grasp, dissect and control bleeding. If there is difficulty encountered with the procedure, the surgeon may have to enlarge the wound to complete the operation. This is termed a "conversion" - and may be associated with higher risk of complications. Bulky tumors that are invading other organs and previous abdominal surgery increase the risk of conversion. Conversion rates often reflect the expertise of the surgeon, and some good centres are achieving conversion rates of <10%.
Hand Assisted Laparoscopic Surgery (HALS)
One technique used by some laparoscopic surgeons is to insert a hand into the abdominal cavity through a special device in order to facilitate the operation. This technique is generally associated with slightly larger wound sizes but it may reduce the incidence of conversion.