Laparoscopic surgery for colorectal cancer

There are two authors of this article because it is necessarily a debate, the gift of reliable prophecy being in general denied even to surgeons. The laparoscopic revolution is rocking the foundations of our institutions and changing every branch of general surgery. It is now urgent that its scope and limits should be defined. A recent BBC Newsnight programme, not sharing our diffidence about prophecy, told the public that 80 per cent of abdominal operc . ens will soon be performed through the laparoscope. The younger author (N.A.O’R.) is impatient to conquer the remaining 20 per cent; the older (R.J.H.) has difficulty believing that the most demanding procedures will ever be better performed without conventional open exposure. The virtual loss of tactile input, the reduced ability to apply direct pressure to control bleeding or to retract powerfully to display tissue planes, the current limitations of two-dimensional video, and the tedious completion of a knot that would formerly have taken seconds, all appear to the senior author tc, be insurmountable obstacles. Is he in danger of becoming a ‘beached whale’, his worid inherited by the ‘young lion’ with the laparoscope? Despite the misgivings of many, demanding colorectal laparoscopic surgery is being performed, in Britain and around the world, for both benign and malignant disease’-3. The required skills and training are considerable and the ‘learning curve’ daunting. All agree that simpler procedures must precede surgery for cancer; rectopexy and colonic resection for benign disease allow surgeons to refine techniques of dissection and to observe for themselves the essential steps of precise rectal mobilization. But is laparoscopic colorectal cancer surgery really worth all the time and expense? Can the young lion persuade the beached whale? Abdominoperineal operations can now be performed without a significant abdominal incision, anterior resection with only a 5-cm wound. Patients have less pain, mobilize sooner and appear to suffer less paralytic ileus and fewer infective problems; but are we sacrificing long-term survival for the sake of a little less pain? We do not yet know local recurrence rates after these new procedures but it seems sensible to assume that long-term outcomes will depend on adherence to established oncological principles. We both believe that resection of a precisely defined tumour package around the primary lesion is the chief determinant of surgical cure4. Careful dissection is needed, as is reasonably proximal pedicle ligation and the prevention of abdominal or staple-line contamination by luminal contents. An unprotected specimen must not be squashed against parietal tissues on removal. Dissection with the laparoscope should be identical to that achieved at open operation. We agree with Monson et al. that the view low in the pelvis may even be better using the laparoscope, but this is not always so as it is easy to stray into the mesenteric fat and create irksome bleeding that can render accurate dissection impossible’. Access to the ‘holy plane’ of rectal surgery can readily be achieved posteriorly and anteriorly, but staying in the plane laterally can be difficult’. Herein lies the basic message: if an accurate tumour excision cannot be done, conversion to an open procedure must be the rule. The surgeon’s good judgement should be applauded rather than surgical timidity condemned. Instrumentation for minimally invasive surgery is becoming both better and more expensive all the time. Use of reusable tools must be encouraged. An extra expenditure of between E500 and El000 is required to fashion an intracorporeal laparoscopic anastomosis after dividing both bowel and vascular pedicle with cutting staplers. The proximal extent of vascular and lymphatic clearance should be the same as that achieved by open surgery. Spillage of luminal contents must be avoided; cutting staple guns can reasonably isolate bowel contents but they may also increase suture-line recurrence by crushing downstream tumour cells into the staple line. A triple-staple technique might facilitate intraluminal washouts below the first staple line and so guard against implantation, as we believe to be necessary6. The present generation of laparoscopic staple guns does not always allow low rectal division, especially in the narrow pelvis. We are concerned by the high percentage of abdominoperineal operations in a recent unselected series’. One would hope that this reflects an unusual referral pattern and not a tendency to take the easy way out and create a ‘minimally invasive sphincter sacrifice’. It may be that ultralow and even low anterior resection for middleand lower-third rectal carcinoma should remain in the domain of conventional surgery. Considering his