Minimally Invasive Surgery Options for Colorectal Cancer Treatment

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• Modern Surgical Approaches for Colorectal Cancer
• Robotic Surgery Benefits and Limitations
• Ideal Candidates for Laparoscopic Colon Resection
• Prioritizing Oncological Outcomes in Surgery
• Contraindications for Minimally Invasive Procedures
• Full Transcript

Modern Surgical Approaches for Colorectal Cancer

Dr. Nelya Melnitchouk, MD, describes several advanced minimally invasive surgical methods for treating colorectal cancer. Laparoscopic surgery involves making small incisions, or ports, in the abdomen and using a camera to guide the procedure. Robotic-assisted laparoscopic surgery, often using the DaVinci system, offers another sophisticated option. For early-stage cancers or large polyps, a combined laparoscopic and endoscopic approach can sometimes remove lesions that were previously unresectable.

Dr. Nelya Melnitchouk, MD, highlights a unique method for early rectal cancer called transanal endoscopic microsurgery (TEMS). This technique is typically reserved for superficial T1 tumors. It allows for a local excision of the rectal cancer, thereby avoiding a major operation to remove the entire rectum. This can significantly improve a patient's quality of life post-operatively.

Robotic Surgery Benefits and Limitations

The choice of surgical technique often depends on the surgeon's training and expertise. Dr. Nelya Melnitchouk, MD, notes that while most surgeons are trained in laparoscopy, robotic surgery is becoming more prevalent. She explains that robotic surgery provides distinct advantages for procedures in the confined space of the pelvis. The robotic instruments offer superior articulation and visualization, making complex maneuvers easier for the surgeon.

However, Dr. Melnitchouk is clear about the current limitations. Robotic surgery is a more expensive option, and large-scale clinical trials are still needed to definitively prove its benefits over other methods. Crucially, there is no current data showing that robotic surgery leads to better survival rates or superior oncological outcomes for colon cancer patients compared to laparoscopy.

Ideal Candidates for Laparoscopic Colon Resection

Laparoscopic surgery is a frequently chosen method for colon cancer treatment. Dr. Nelya Melnitchouk, MD, explains that this approach offers significant patient benefits when it is clinically appropriate. Patients typically experience a shorter hospital stay, less post-operative pain, and a lower risk of developing incisional hernias due to the smaller incisions. These advantages contribute to a faster and more comfortable recovery process.

The decision to proceed laparoscopically is a careful one. The potential for improved recovery must never compromise the primary goal of the operation: to cure the cancer. The procedure must be technically feasible for the surgeon to perform a complete resection with clear margins.

Prioritizing Oncological Outcomes in Surgery

Dr. Nelya Melnitchouk, MD, emphasizes that the oncological result is the most critical factor in any cancer surgery. The primary objectives are an R0 resection, meaning no microscopic cancer cells are left at the margin, and the retrieval of at least 12 lymph nodes for accurate staging. This often requires a high ligation of the mesentery.

During his discussion with Dr. Melnitchouk, Dr. Anton Titov, MD, explores how surgeons balance technique with outcome. A surgeon will only choose a minimally invasive method if they are confident they can achieve these gold-standard oncological goals. The convenience of a faster recovery is a secondary benefit that only matters after the cancer is completely removed.

Contraindications for Minimally Invasive Procedures

Not every patient with colorectal cancer is a candidate for minimally invasive surgery. Dr. Melnitchouk outlines several scenarios where an open procedure is necessary. Very large tumors or cancers that have grown into adjacent organs (like the duodenum, liver, or kidney) require a major en bloc resection. This involves removing the tumor together with the involved section of the other organ, which is often best done through a traditional open incision.

Certain patient health factors also preclude minimally invasive techniques. The pneumoperitoneum, or insufflation of the abdomen with carbon dioxide, and specific patient positioning required for laparoscopy can be poorly tolerated. Patients with significant underlying heart or lung disease may not be stable enough for this approach, making open surgery the safer option. Dr. Melnitchouk concludes that careful patient selection is paramount to achieving the best possible results.

Full Transcript

Dr. Anton Titov, MD: Minimally invasive surgery methods are now available for colon cancer and for rectal cancer patients. What minimally invasive colorectal cancer treatments are available to patients today?

Dr. Nelya Melnitchouk, MD: We have many surgical methods to treat colon cancer or rectal cancer. You can do surgery laparoscopically. It means small incisions and the camera. Surgeons are doing the surgery with small holes in the abdomen. They are called "ports". Robotic surgery plays a role. Robot-assisted laparoscopic surgery is similar to laparoscopy except that you use the DaVinci robot.

Colorectal cancer could be in an early stage. It could be a colon polyp that cannot be removed just endoscopically. Then a surgeon can combine laparoscopic surgery and an endoscopic method. A surgeon can remove an otherwise unresectable polyp.

Rectal cancer has unique minimally invasive surgical treatment methods. Transanal endoscopic microsurgery is available for early rectal cancer, usually a T1 tumor. This is a very superficial rectal cancer. You avoid the big operation to remove the whole rectum. A surgeon performs a local excision of rectal cancer.

Dr. Anton Titov, MD: How does a surgeon choose the best method of colorectal cancer treatment? How to choose the correct minimally invasive colon cancer or rectal cancer treatment?

Dr. Nelya Melnitchouk, MD: Many treatment decisions depend on the training of the cancer surgeon. The majority of cancer surgeons today are trained in laparoscopic surgery. Laparoscopic surgery for colon cancer is happening more often in this country. The majority of colon cancer treatment can be done laparoscopically.

We are still learning the benefits of robotic surgery. We have to do clinical trials to truly show the benefit of robot-assisted surgery in colon cancer. Because robotic surgery is expensive. Results of robot-assisted surgery depend on both the patient’s situation and the training of surgeons.

Robotic surgery does have some benefit in the pelvis. Because otherwise it's very difficult to reach into the pelvis. It is difficult to visualize the structures. A robotic instrument gives you better articulation. Robotic surgery can make it easier to do the surgical procedure.

We don't have any data that results of surgery are better from robotic surgery. We don't have any data that survival of patients is better from robotic surgery.

Dr. Anton Titov, MD: Let’s focus on laparoscopic treatment of colon cancer. When does it make sense for patients with colon cancer to have a laparoscopic resection? When is laparoscopic surgery not advantageous for a patient?

Dr. Nelya Melnitchouk, MD: We are talking about cancer. Obviously, cure from cancer is the most important goal. But convenience in laparoscopic surgery is also important. Sometimes laparoscopic surgery does make sense. Sometimes it does not make sense. That's a very good question.

A patient may choose a minimally invasive option to treat colon cancer or rectal cancer. It is very important not to have a poor oncological result. A surgeon must be able to resect the cancer with a negative margin (R0 resection). A surgeon must get at least 12 lymph nodes. It means you have to do a high ligation on the patient’s mesentery.

A surgeon may be able to do that laparoscopically. Then laparoscopic surgery is a method of choice. Because patients do benefit from laparoscopic surgery postoperatively. They have shorter lengths of stay in the hospital. Patients have less pain after a laparoscopic surgical operation. Patients probably have fewer hernias. Because the incision is smaller in laparoscopic surgical operation for colorectal cancer.

But a surgeon does not want to do laparoscopic surgery and then leave a positive tumor margin. A surgeon should not leave some cancer behind. A colorectal tumor could be very large. Or the tumor could be growing into other organs. Colon cancer could be growing into a duodenum or retroperitoneum or kidney or liver.

Then a surgeon has to do a big en bloc resection. It means the following: cancer is removed all together with other adjacent organs. In such situations, laparoscopy does not make sense.

We also have some patients that will not tolerate laparoscopy. Some patients have problems with their lungs. Other patients have heart problems. They may not be able to tolerate laparoscopy. Because laparoscopic cancer surgery requires different positioning of the patient. Laparoscopy requires insufflation of the abdomen with carbon dioxide. Some patients will not tolerate that.

Then the colorectal cancer tumor is removed via open surgery. It is all about patient selection.