The surgery for colo-rectal neoplasms involves the removal of the portion of the diseased colon (with a large safety margin with respect to the carcinoma site) and all the vessels and lymph nodes that are located in the vicinity of veins and arteries intended for that stretch. For example, if the tumor is located on the right, near the appendix, it will be necessary to remove the entire right colon; the same is true for carcinomas found on the left side. As for the tumors that arise in the last 15 cm of the large intestine, or at the level of the rectum, it is necessary to make a separate discussion.
What should be done in case of rectal cancers?
In this case, a careful preoperative study is necessary to establish the distance of the tumor from the anal sphincter. If this distance is too small, the removal of the intestine and sphincters as a whole would be necessary, which will oblige the patient to evacuate the feces in a bag for life. Currently, however, in a large part of the cases, it is possible to save the anal sphincter either by subjecting the patient to a pre-operative radio and chemotherapy treatment, or by using sophisticated surgical dissection systems, with a minimally invasive technique, which allow to remove radically the tumor leaving the sphincter free. In other cases, in the presence of intestinal obstruction or bleeding, the intervention must be carried out in two stages. In the first half the tumor will be removed and a colostomy will be made and, in the second, the intestine will be reconnected.
The advent of the minimally invasive technique in colorectal surgery
Over the past 30 years, laparoscopic surgery has rapidly expanded its indications, causing revolutionary changes in the treatment of surgical diseases of the abdomen. Since the beginning of the 90s laparoscopy also included colorectal surgery, but the use of minimally invasive techniques in this type of surgery has had a slow and, in some respects, contrasted evolution. The first minimally invasive resection was performed in 1991 and then spread more and more, initially for benign pathologies (diverticula and polyps) and later also for neoplastic pathologies (such as colorectal cancer).
What are the advantages of the laparoscopic technique?
The laparoscopic technique allows not only to perform oncological interventions in the most correct way, but to carry out more precise and meticulous dissections thanks to the magnification of the images and the possibility of reaching areas otherwise difficult to see with the camera. The classic midline incision, which normally extends from the pubis to the sternum, is replaced by 2 incisions of 10 mm (one in the suprapubic area, for the extraction of the organ) and 2 by 5 cm.
Precisely for these advantages and for the use of complementary therapies (chemo and operative radiotherapy), able to reduce the size of the neoplasm, the need to resort to definitive colostomy operations (total removal of intestine and sphincters) has drastically reduced.
In addition, the reduced post-operative pain allows the patient to get up early from the bed and walk the day after the operation, thus improving muscle recovery times, a fundamental aspect of postoperative treatment in older patients. In addition to this, the short bedtime reduces lung stasis and respiratory complications, allowing the patient better sitting breathing. The activity of the intestine also quickly resumes and the patient will be able to feed after a few days, thus restoring a metabolic and water balance. The faster post-operative recovery also allows you to start any postoperative oncological therapies first, with the consequent benefits.
Finally, the adoption of targeted anesthesiology techniques and postoperative pain relief therapies, associated with minimally invasive surgery techniques, has now made it possible to achieve the concept of “painless surgery”.
What cancer results does it offer?
The techniques of laparoscopic surgery of colorectal cancerare now standardized and the laparoscopic approach is more and more frequent, since it has been widely demonstrated that it is a reliable technique, which allows to achieve the same results and with many advantages compared to the traditional intervention. After an initial period of skepticism and distrust, today it can be said with certainty that with laparoscopic surgery the same operations that can be performed with the traditional technique can be performed. These excellent results are attributable first of all to the increase in experience and subsequently to the availability of increasingly technologically advanced instruments, which allowed the improvement of the techniques and consequently made the minimally invasive interventions safer and with less complications.
Are there contraindications to the minimally invasive technique?
The minimally invasive technique for the removal of a colorectal carcinoma may not be indicated in case of extremely large neoplasms or that infiltrate the neighboring organs, for which the intervention conducted in the traditional way is safer, or in case of patients subjected to previous abdominal operations or, finally, in patients with intestinal obstruction. Furthermore, it is possible that during laparoscopic surgery it is necessary to change the technique and switch to open surgery, for example in the case of large neoplasms, complications or particular anatomical situations.
What are the future goals?
Laparoscopic surgery has perhaps been the most significant surgical step forward in the past 30 years. At present, almost all surgeries can be performed laparoscopically. After showing that the minimally invasive technique offers the same results as the traditional one in the removal of colorectal carcinomas, it is necessary to confirm the actual long-term clinical impact of the above mentioned advantages.
Furthermore, let’s not forget that laparoscopically operated patients who need chemotherapy (about 70%) can start it earlier than the others, since their recovery times are shorter. This is the objective of the research in the coming years: to demonstrate that in addition to the immediate benefits (already demonstrated), the minimally invasive technique applied to colorectal neoplasms also offers long-term benefits and is able to improve the oncological result.