Laparoscopy in oncology — Current Trends

Although it is over a hundred years since the initial development of laparoscopy

Although it is over a hundred years since the initial development of laparoscopy, it is only in the past three decades that there has been a revolution in the field with surgeries like laparoscopic cholecystectomy becoming the gold standard worldwide.

Advantages of laparoscopic surgery are well known, and include dramatically reduced hospital stay, better patient comfort, rapid return to employment, lesser tissue handling and superior cosmesis compared to open surgery. Further, there is better visualization and magnification especially in areas like the pelvis and the thorax which are often difficult to access in open surgery. Systemic immune competence has also been shown to be better preserved after laparoscopic surgery.

The role of laparoscopy for cancer has expanded to include diagnosing, staging, treating, monitoring, and palliating many types of malignancies. Laparoscopic guided biopsy allows the confirmation of malignancy by providing tissue specimens, especially in cases where other means of biopsy are not feasible.

Laparoscopic staging can identify unresectable disease, which often dramatically alters therapy. With increased accuracy in staging, many patients can avoid pain and prolonged hospital stay of a nontherapeutic laparotomy

For resectable disease, a wide range of curative laparoscopic resections have been described. However, it is imperative that the laparoscopic oncosurgeon follows all the principles of surgery for cancer just as in open operations. The principles of laparoscopic onco-resection include :

(1) Maintenance of the integrity of the oncologic resection (e.g., margins of resection, lymph node dissection)

(2) Demonstration of improved outcome parameters for the resection (e.g., decreased hospital stay, decreased pain, decreased cost, more rapid return to work), and

(3) Absence of any negative impact on survival (e.g., induction of carcinomatosis or metastasis by laparoscopy, portsite recurrences).

Colorectal Cancer is one of the malignancies in which extensive research has been done comparing open versus laparoscopic resection (COST trial, CLASSIC trial, COLOR trial) and it has been shown that there is no compromise in oncologic outcomes with laparoscopic surgery. Other cancers which are amenable to laparoscopic resection include cancers of the esophagus, stomach, small intestine, kidney, adrenal, spleen (hematologic), pancreatic tail, some liver tumors, and gynaecologic cancers.

The role of laparoscopy extends beyond diagnosis and treatment. Many a time, patients with incurable cancers need palliation of their malignancy. A common scenario is gastric outlet obstruction or intestinal obstruction. When the gastric outlet is obstructed by a tumor such as an incurable gastric or pancreatic cancer, a laparoscopic stapled gastrojejunostomy can be performed quickly to provide pain relief and allow resumption of eating. Intestinal stomas can also be created when bowel loops are involved with tumor and intestinal bypass is not feasible.

Laparoscopic surgery is heavily dependent on technology. With rapid evolution in the field of technology, we now have available excellent telescopes and camera systems, high-definition monitors, high end energy sources and tissue sealing devices, and staplers manufactured for laparoscopic use. There are also many opportunities for the interested surgeon to train himself/herself in laparoscopic oncosurgery in India as well as abroad.

With this, it is clear that laparoscopic oncosurgery has proved to be a boon for many patients. With time, more and more patients will be offered this modality of treatment, so that they can also enjoy its potential benefits.