Laparoscopic Colorectal Surgery

Most people are familiar with laparoscopic, minimally invasive (MIS) or keyhole surgery of the gallbladder but not with the colon or rectum. Following the success and worldwide acceptance of laparoscopic gallbladder surgery, colorectal surgeons started to develop laparoscopic colorectal surgery in the early 1990's. Unlike gallbladder surgery, colorectal surgery involves a much wider area of the abdomen and is often for malignant disease, therefore technically the procedure is much more challenging. There was also a genuine concern that it was not as good as open-surgery for treating cancer. Early enthusiasm for laparoscopic colorectal surgery was quickly replaced by reality, and laparoscopic colorectal surgery was confined to a few centres in the world to develop the procedure and conduct proper clinical trials.

In the last few years, evidence started to emerge that laparoscopic colorectal surgery is as effective as open surgery in treating cancer. This culminates in the publication in the New England Journal Medicine in May 2004 with the conclusion: “In this multi-institutional study, the rates of recurrent cancer were similar after laparoscopically assisted colectomy and open colectomy, suggesting that the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.”

At the same time, new instruments for bloodless dissection, blood vessel sealing and hand retraction have been developed to make laparoscopic colorectal surgery much easier. Now there is a renewed enthusiasm for the procedure because of its advantages over open surgery. They are:

• Much shorter scar;
  
• Wound infection rate is reduced 50%;
  
• The period of ileus-when the intestine stops moving because of the operation-is reduced 33%. This means patients can drink and eat much earlier;
  
• Recovery time of normal breathing – measured by peak expiratory flow is 44% quicker;
  
• Pain is reduced 35%;
  
• Hospital stay is reduced 20%;
  
• There is less suppression of the immune system, which may be important when treating cancer;
  
• With long-term follow-up, patients after laparoscopic surgery are less likely to experience abdominal pain and intestinal obstructions from adhesions. In Singapore, post-operative adhesions or scarring are a common cause of abdominal pain and intestinal obstruction, which sometimes requires more operations;
  
• With smaller incision, there is less likelihood of incisional hernia.

Not all colorectal abdominal surgery can be approached laparoscopically. In patients with abdominal scars and adhesions from previous operations, laparoscopic surgery is usually not possible. When a patient requires emergency or very quick surgery, open surgery is preferable. When colorectal cancers are too big, are stuck to abdominal wall, invade surrounding organs or cause obstruction, laparoscopic surgery is not recommended.

With its clear advantages over open surgery, laparoscopic colorectal surgery will become routine in the future. The time to achieve this is determined by the time it takes colorectal surgeons to overcome the technical difficulties of the procedure.