JSLS Laparoscopic Colectomy: the Absolute Need for a Standard Operative Technique E. Croce, M. Azzola, R. Russo, M. Golia, S. Olmi ABSTRACT Background: The aim of this study is to review our expe- rience performing laparoscopic colon surgery and to pre- sent the operative technique as used and standardized by us. Methods: From April 1992 to December 1996, 158 con- secutive patients underwent laparoscopic colon surgery. There were 92 females and 66 males, whose average age was 66.7years (range 31 - 92); 134 patients (84.9%) were operated on for carcinoma, and the remaining 24 (14.1%) for benign disease. Results: There were 117 procedures completed laparo- scopically out of 158 patients (74%); 103 colon resections (18 for benign disease and 95 for malignant disease), 7 Hartmann procedures, 3 for reversal of Hartmann's proce- dures, 1 rectopexy, and 3 ileotrasversostomies. Conversions were required in 41 out of 158 cases (25.9%); 19 of these cases, however, were converted to a laparo- scopic-facilitated procedure. The most common causes for conversion were the presence of bulky tumors and/or tumors that contaminated adjacent structures (16/158), adhesions due to previous operations (8/158) or patient obesity (5/158). There were 31 complications (19.6%), 9 of which required re-operation. There was only one recur- rence (0.9%) that manifested 15 months after the proce- dure, at both trocar and drainage sites, and with peritoneal carcinomatosis. This occurred in a patient with rectal neo- plasia who suffered a perforation of the rectum duringdis- section, with bowel spillage. The average number of lymph nodes harvested in resected specimens was 12.8 (range 1-41), whereas the mean distance of the tumor from the proximal margin of resection was 11.5cm (range 5-35), and from the distal margin 7.5 cm (range 1-25). The aver- age operative time was 165 minutes (range 40-360), and the mean hospital stay was 9.2 days (range 6-40). There were three mortalities out of 158 patients (1.9%). Conclusions: Laparoscopic colon resection for malignant lesions, performed with the highest respect for oncologic principles, has demonstrated that it is difficult to develop a 1st Department of General and Thoracic Surgery, Center for Minimally Invasive Surgery; Fatebenefratelli Hospital, C.so Porta Nuova, 23, Milan - Italy. Address reprint request to: Dott. Stefano Olmi, Via Solferino, 42, 20121 Milano - Italy. Telephone: 0039/2/6363461-431, Fax: 0039/2/6363460, E-mail: olmi@mi.flashnet.it barrier to wall and intraluminal recurrence. Recurrence, in our opinion, is caused by improper surgical technique. Therefore, neoplastic colon laparoscopic surgery must be the prerogative of selected and specialized centers. Key Words: Laparoscopy, Colorectal tumors, Wall recur- rence, Surgical technique of colon resections. INTRODUCTION In laparoscopic colorectal surgery, the adherence to radical principles of oncology has always been a controversial issue. The need for a standard procedure in laparoscopic colon surgery that follows the oncologic principles of tradi- tional surgery is highlighted by the rise in recurrences at both trocar sites and the minilaparotomy through which the specimen is removed. We firmly believe that such recur- rences are caused by improper surgical technique or by the lack of adequate theoretical and practical preparation by the surgeon.4 Laparoscopic colon surgery requires consid- erable experience in the field of traditional colon surgery and a long learning curve. An excellent knowledge of laparoscopic technique, manual dexterity and technical maturity is required that is only acquired after having per- formed operations with increasing levels of difficulty.8 The main oncologic principles in performing a correct colon resection are summarized as follows: 1) Avoid touching the tumor (no-touch technique). As many have pointed out, this contact is responsible for intraperitoneal neoplastic dissemination.3,4,7 Instruments, gloves and retractors may be infected with the tumor cells. As an increasing number of wall recurrences are recorded in the literature, it is clear that some surgeons perform a "touch technique." 2) First ligate the vascular pedicles. 3) Execute an adequate lymphadenectomy with the removal of the mesentery to the involved segment.3,6 4) Develop proper resection margins.3,6 5) Perform a minilaparotomy appropriate for the size of resected bowel in order to avoid "squeezing" the tumor. From a functional, clinical or cosmetic point of view, a 7-8 cm incision instead of a 3-4 cm incision is, in our opinion, of little importance when compared to the risk of wall recurrence.5,7 6) Protect the minilaparotomy site through which the JSLS (1997)1:217-224 217