Laparoscopic colorectal resection was first described in 1991. Althought it has advantages for patients over the open technique and several studies have concluded for the same oncologic results between open and minimal invasive techniques, laparoscopic approach is still not the most frequent worldwide used. Why? Challenges in aquiring technical competence, learning curve and recurrence at port sites, all work together to justify why some surgeons do not perform laparoscopic colorectal resection.
Laparoscopic colorectal resection was first described in 1991 and it is still not the most frequent worldwide used. Why?
In the present day it looks clear that laparoscopic resection decreases complications rate, shortens recovery and in-hospital post-operative days, and decreases the need for pain-killers. For some authors, laparoscopic approach in conjunction with an enhanced recovery after surgery (ERAS) program should be the gold standard. Is laparoscopy suitable for all patients? No it is not. Some complex cases with previous abdominal operations still need open surgery. In order to reduce conversion rate, a good patient selection is needed, and surgeons must fight the "laparoscopy for all" idea.
Conventional laparoscopic colonic resection use a five port technique. This is also my preffered approach. I use it for both right and left hemicolectomies. Some authors are trying to reduce port number. Is it necessary? Will it have the same results? Will this reduction have a positive impact in aesthetic outcome?
Dr Kim et al from the Department of Surgery of the Gyeongsang National University Hospital in Republic of Korea, published a paper comparing a three-port technique with the conventional five-port technique for laparoscopic right hemicolectomy. They included 163 patients diagnosed with right colon adenocarcinoma and submitted to laparoscopic resection. From those, 74 were submitted to a 3-port laparoscopic rigth colectomy (3-LRC) and 89 to a 5-port laparoscopic right colectomy (5-LRC).
Conventional laparoscopic colonic resection use a five port technique. Some authors are trying to reduce port number.
I only had access to the abstract in which the authors present results that are both interesting and unbelievable. I explain...
Kim et al state both groups were identical in TNM stage, conversion to open surgery, blood loss and complications rate. However, in other points there were significant differences (p<0,05):
Operation time was shorter in the 3-LRC group (a mean of 38 min less)
Number of harvested lymph nodes was higher in 3-LRC groups
First oral intake and first passage of flatus were faster in the 3-LRC
Is there any believable justification for these results? They also concluded that patients operated with three ports had a less need for analgesics. Althought there are only 2 small incisions less, this conclusion I can accept.
The 3-LRC takes less and dissects more. Is this real?
How can a 3-port technique reduce operation time in 38 minutes? I do not believe they take 30 minutes to place two ports. A possible justification is the need for a constant and coordinate work between surgeon and first assistant. Surgeon and first assistant must move the graspers in accordance with each other. Sometimes this is not easy and is time consuming. However, a 3-port technique means the surgeon must work alone, and sometimes difficulties in exposing structures will arise and will be time consuming.
Is the less number of harvested lymph nodes in the 5-LRC group I can not accept. How can this be justified? The same surgeon is operating and doing the same procedure. How can a two port less technique be better for lymph node dissection? Adding the previous result, a 3-port technique takes less and dissects more. Is this real? I think more studies from different surgery departments are needed. For now, I think it is hard to believe these results will be constant following future trials.
Third point, oral intake and passage of flatus. These were both faster in the 3-LRC group. As this was not a double blinded study, the authors may have been suggested or even encouraged to accelerate oral intake in group 3-LRC. I can not tell...
The considerations I make are doubts I have. I do not like to accept all results from any kind of study without any questions, and I believe none of us should. Read, analyse, and question methods and results is important to evolve.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon