ROLE OF LAPAROSCOPY IN MANAGEMENT OF COLORECTAL CANCER

Abstract

SUMMARY C olorectal cancer is one of the predominant types of cancer and the fourth leading cause of cancer-associated deaths worldwide (World Health Organization, 2013). Most colorectal cancers are due to old age and lifestyle factors with only a small number of cases due to underlying genetic disorders. Some risk factors include diet, obesity, smoking, and lack of physical activity. Dietary factors that increase the risk include red and processed meat as well as alcohol (World Cancer Report, 2014). The clinical presentation may be acute, either as intestinal obstruction (abdominal pain, intestinal hyperperistalsis and closing) or intestinal perforation or chronic manifestations which are highly variable and depend on the location of the tumor (Bresalier, 2002). The diagnostic strategy in CRC with acute symptoms of obstruction is established by optical colonoscopy or if incomplete or contraindicated, with CT colonography (CTC). In such cases with suspected bowel perforation or colonic occlusion the diagnosis is usually made by abdominopelvic CT or through straight surgery (Jover et al., 2012). Once a diagnosis of colorectal cancer has been made and the patient’s views taken into consideration, future treatment is dependent on the stage of the disease and the patient’s co-morbidities. Colorectal cancer staging is fundamental in deciding whether the tumour is amenable to surgical resection and whether treatment is likely to be curative or palliative (Simpson, 2008). The most appropriate method of obtaining local control of a colonic tumour is radical excision of the affected section of colon along with its vascular pedicle and accompanying lymphatic drainage,because the lymphatics of the colon accompany the main arterial supply (Ricciardi et al.,2006). An anterior resection of cancer rectum involves removal of the upper rectum with anastomosis of the colon to the rectal stump, whereas an abdominoperineal resection of the rectum (APER) requires complete excision of the rectum and anal canal with formation of a permanent end colostomy (Simpson, 2008). The surgeon must be familiar with the fascial attachments of the colon, which can be used for countertraction during laparoscopic resection (Franks et al., 2006). Laparoscopic right hemicolectomy incude: mobilization of the cecum and ascending colon, mobilization of the hepatic flexure, division of the ileocolic pedicle and mesentery, exteriorization of the specimen, resection and anastomosis (Veldkamp et al., 2004). Laparoscpic left hemicolectomy include: mobilization of the sigmoid and descending colon, mobilization of the splenic flexure, division of the inferior mesenteric vessels, division of the colon and exteriorization of the specimen, resection, and anastomosis. ERAS is the strategy of perioperative care in colorectal surgery and among the main principles, restrictive intravenous fluid therapy, use of laparoscopy in combination with appropriate anesthesia, analgesia with early enteral feeding and early postoperative mobilization seem to be most important (Nygren et al., 2013). The learning curve is defined as the number of cases that a surgeon needs to have in order to perform a procedure with guaranteed results based on comparisons with the results obtained with the previous technique (Park, 2009). A number of techniques to prevent port-site metastases where in addition to the general oncologic principles after resection, consider irrigation of trocar sites with 5% betadine before removal, bag the specimen,protect extraction site and irrigation of trocar sites with Betadine and water (Balli et al., 2000). The advantages of laparoscopic surgery in convention to open technique incude reduced blood loss, less postoperative pain, better pulmonary function, faster return of bowel function, fewer complications, and shorter hospital stay (Van, 2013). The major disadvantage of laparoscopic colectomy is increased operative time. Surgeon's experience is important, and there is a significant learning curve for laparoscopic colectomy. It is noted that operative time decreases significantly the greater surgeon's experience (Lacy et al., 2004).