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Minimally invasive surgery in cancer of the colon
In terms of indicators of oncological quality (R status, number of lymph nodes) and long-term results (tumor recurrence, survival), with surgeons of appropriate expertise single-center and multicenter RCTs (KOLOR, COST, CLASSIC-Trail) showed no difference between laparoscopic and open techniques in colon cancer surgery [1, 3, 4]. One benefit of minimally invasive surgery was a rather low short-term perioperative morbidity, while the overall morbidity and mortality remained unchanged [9].
According to the current German S3 guideline on "Colorectal carcinoma", laparoscopic resection of colon cancer may therefore be performed in appropriate cases, if the surgeon has suitable experience [8]. At present there is no evidence for the NOTES technique in colon cancer.
Laparoscopic colon resections are demanding procedures whose learning curve plateaus only after at least 88 resections [6]. At 20% the percentage of resections in cancer of the right colon is rather low at present, and these procedures are usually performed as laparoscopically assisted resections in which the parts of the bowel to be anastomosed are exteriorized via laparotomy.
SILS, NOTES and robotic surgery
Development in minimally invasive surgery pursues two main avenues
- Further reduction of the access trauma (SILS, NOTES)
- Improved precision in instrument control and dissection (robotics)
Access trauma can be reduced by SILS (Single Incision Laparoscopic Surgery), where unlike in conventional laparoscopy, the instruments are introduced via a single-port system. Another option is the NOTES technique (Natural Orifice Transluminal Endoscopic Surgery) which relies on natural body openings for instrument insertion.
Makino et al already reported on the technical feasibility and safety of single-port colon surgery in a systematic review in 2012 [5]. With an adequate number of resected lymph nodes and tumor-free specimen margins, compliance with oncological standards is possible in principle with SILS. However, the present review emphasizes the highly selected patient population and the surgeon's special laparoscopic expertise. Regarding the hoped for cosmetic benefits, it must be admitted that in these operations the length of the incision is mostly determined by the specimen retrieval and less by the port used.
At present there is no evidence for the NOTES technique in colon cancer.
The situation is different for robotic surgery of colon cancer. Case series demonstrate that robotics can be safely used in colon cancer surgery and yields benefits in terms of tissue sparing and less postoperative dysfunctions [2, 10]. Regarding the short term and especially the oncological long-term results, at present robotics assisted surgery in colon cancer cannot be recommended outside of studies because of the inadequate evidence [7].