Surgery offers the best opportunities for curing colorectal cancer. But long incisions and extensive manipulation of the bowel during surgical procedures do take a toll in terms of post-operative pain and recovery time. To reduce these adverse effects, surgeons and manufacturers of surgical instruments have teamed up to develop techniques that can reach and remove a tumor with as little disruption to the abdominal cavity as possible. Today the techniques include laporoscopic surgery and robotic-assisted surgery. Both are performed through small incisions, and therefore are called minimally invasive. LAPAROSCOPIC SURGERY Instead of long incisions and a surgeon’s hands to perform conventional surgery, laparoscopic surgery relies on a few very small incisions, and several delicate instruments, thus creating a smaller impact on the body. For this reason, laparoscopic surgery is also referred to as minimally invasive surgery, or MIS.
The preparation and anesthesia for laparoscopic surgery is the same as was described earlier in the open surgery chapter. When you are properly anesthetized, the surgeon will make several small incisions in the skin. The incisions will be 5-12mm (about a quarter- to half-an-inch). Some of these incisions will be used to inject carbon dioxide into the abdomen in order to push the abdominal wall away from the intestine and allow the surgeon to work. Special tubes, called trocars, or ports, will be used to insert delicate tools, including a viewing device called a laparoscope, and to perform the surgery. The surgical team will operate by manipulating the instruments from outside while watching their work on a high definition video monitor. A laparoscopic colectomy is technically more challenging than open surgery. The procedure can take from two to four hours. Laparoscopic surgery of the rectum is even more difficult than laparoscopic colon surgery. The rectum sits in the narrow pelvis surrounded by tight bony structures and many important organs such as the bladder, the prostate or vagina, and the pelvic nerves that are responsible for proper sexual and urinary function. Because of this, laparoscopic surgery of the rectum can take three to six hours. Benefits of Minimally Invasive Surgery Many studies have shown that laparoscopic surgery offers many benefits when compared with traditional open surgery. The benefits include • Small incisions with reduced pain • Less blood loss and lower rate of transfusions • Reduced need of narcotic pain medication • A faster return of normal bowel function • Faster recovery, with fewer hospital days • Markedly higher quality of life
Overall, shorter recovery time with reduced narcotic use and quicker time to first bowel movement, oral intake, and normal diet translate into shorter hospital stays.
Risks and Complications The rate of complications of laparoscopic colectomy is overall the same as for open surgery. The rates of wound infections and subsequent scar formation and hernia formation are all lower with a minimally invasive approach. The specific complications, such as bleeding, perforation, infections and others, have been discussed in an earlier chapter. What is different about laparoscopic procedures is that they are quite demanding technically. The surgeon’s experience is important, and there is a significant learning curve. In the hands of a surgeon who has not received adequate training, or hasn’t yet performed a large number of these procedures, the complication rate may be significantly higher. Since rectal surgery is even more challenging than colon surgery, it goes without saying that technical errors during rectal surgery can have dramatic consequences on postoperative recovery and on your future. If you are considering a laparoscopic procedure, you should find a surgeon who has considerable experience with laparoscopic colon surgery before agreeing to have the operation. It is helpful to assess a surgeon’s expertise by asking how many similar operations he or she typically performs in one year, and whether he or she has published or given lectures in the field. Although studies have shown that minimally invasive rectal surgery is safe and results in better recovery compared with open rectal surgery, it must be stressed that there are only a handful of centers around the country that have sufficient experience with this approach.
Is Minimally Invasive Surgery Right for Me?
Unless there are specific reasons why a laparoscopic approach cannot be performed, (these are rare: multiple prior operations for intra-abdominal infection, tumors invading other organs) most patients can be treated with laparoscopic surgery. In the hands of the right surgeon, any segment of the colon can be removed via a laparoscopy. Studies have shown that even obese patients and patients who have had prior surgery can have, and greatly benefit from, minimally invasive surgery. Minimally invasive colorectal surgery is rapidly becoming the standard of care for surgical treatment. In 2005, 15% to 20% of colectomy procedures used a minimally invasive approach. By 2014 it is projected that 65% of colectomies will be performed laparoscopically.