Laparoscopic colon resections are being performed with increasing frequency in the United States, though the use of minimally invasive techniques in colorectal surgery has lagged behind its application in other surgical fields. Since the first laparoscopic colectomy was described in 1991, a great deal of controversy has surrounded its use, particularly in the management of colorectal cancer. Several important new studies1–3 have demonstrated the benefits and safety of laparoscopic colorectal surgery, making it now the preferred approach in the surgical management of many colorectal diseases.

Are There Immune Benefits to Laparoscopic Surgery?

A consequence of those early concerns was an increasing interest in understanding the physiologic consequences of surgery, both open and laparoscopic, and its effects on tumor biology and immune function. It is well known that surgery leads to transient immunosuppression, though the underlying etiology remains unclear. A well-known cascade of physiologic and immunologic responses occurs after surgery. Inflammation involves the recruitment of macrophages and neutrophils at sites of tissue injury, release of proinflammatory cytokines and growth factors to promote wound healing (and that may also stimulate tumor growth), and activation of T cell (cellular) and B cell (humoral) immunity. Surgery has been shown to dampen each of these responses, leading to varying degrees of immunosuppression. Laparoscopic surgery, which is associated with less patient trauma through smaller incisions and less postoperative pain, may be associated with less immunosuppression, compared with open surgery, though the data remain a subject of debate and the clinical significance of this effect remains unclear.

How Is Laparoscopic Colectomy Done?

The technique of laparoscopic colectomy has a long learning curve because of the advanced laparoscopic skills it entails. Unlike other laparoscopic procedures, such as the Nissen fundoplication or cholecystectomy, colorectal procedures involve dissection and mobilization of intra-abdominal organs in multiple quadrants. Laparoscopic colorectal surgery involves the use of several small incisions through which a specialized camera and several laparoscopic instruments are inserted (Figures 1, ​,2).2). An insufflator blows carbon dioxide (CO2) into the peritoneal cavity, creating a pneumoperitoneum that provides a working space to perform the operation. Tilting of the operating-room table in various positions during an operation uses gravity to allow intra-abdominal organs to fall away from the area of dissection, providing necessary exposure that would normally be achieved through the use of retractors. Intestinal resection requires laparoscopic ligation of large vessels, mobilization and removal of a long floppy segment of colon, and restoration of intestinal continuity. Once the colon segment has been completely mobilized and its blood supply divided, a small skin incision is made to exteriorize the colon, a resection and anastomosis are performed extracorporeally, and the rejoined colon is placed back into the abdomen.

Indications, Advantages, and Disadvantages of Laparoscopic Colectomy

Most patients are candidates for a laparoscopic approach. When the surgeon is experienced, even patients with a history of abdominal surgery are candidates. Though there are clear benefits, they have not been as compelling when compared to the clear advantages associated with other laparoscopic procedures. The main reason is that a colectomy, whether open or laparoscopic, results in a delayed return of bowel function. Though recovery of bowel function is quicker after laparoscopic surgery, the difference is on the order of one or two days, resulting in a similar reduction in length of hospital stay. Also, the laparoscopic approach is associated with longer operating-room times. Even if long-term benefits are equivalent between open and laparoscopic techniques, the short-term benefits are real advantages for patients. In practical terms, the laparoscopic approach is associated with less pain, a faster recovery, earlier return of bowel function, a shorter hospital stay, possible immune benefits, and smaller scars, making it the preferred method for intestinal resection.

Technical Pearls—Use of Carbon Dioxide Colonoscopy

The lack of tactile feedback during laparoscopic surgery can make tumor localization difficult, especially if the lesion location has not been tattooed on the colon wall before surgery. It is imperative that the exact location of the tumor is known prior to proceeding with colectomy. Even when the lesion location has been tattooed onto the colon, often the mark can be difficult to see, or there may be confusion regarding the location of the tattoo in relation to the tumor (proximal or distal), which can affect surgical margins. Intraoperative colonoscopy is a way of definitively localizing a lesion and should be available during all laparoscopic colectomies. Traditional colonoscopy uses room air as the insufflating gas, which leads to significant bowel distension and requires clamping of the proximal colon to minimize this effect. Clamping the bowel can lead to injury, and even when it is successfully performed, the degree of distension often makes simultaneous laparoscopic visualization difficult. These problems can be circumvented with the use of CO2, rather than room air, as the insufflating gas (Figure 3). Because CO2 is absorbed much more rapidly than room air, bowel distension is minimized and dissipates quickly, making proximal clamping unnecessary. Use of CO2 allows for laparoscopic and endoscopic procedures to be performed simultaneously (Figure 4), and this technique has been shown to be safe and clinically useful.17 Besides tumor localization, CO2 colonoscopy may have other potential applications.

What Is the Future of Laparoscopic Colectomy?

Laparoscopic techniques are currently used in the surgical management of diverticulitis, Crohn’s disease and ulcerative colitis, familial polyposis, rectal prolapse, and benign and malignant colorectal neoplasms. As technology moves forward, minimally invasive surgery continues to evolve. Endoluminal approaches are being explored as an alternative or complimentary surgical technique.

Combined laparoscopic and colonoscopic procedures may bridge the gap to future developments in endoluminal surgery. In the past, simultaneous laparoscopy and colonoscopy was technically difficult because colonoscopy used room air as the insufflating gas, leading to significant bowel distension that obscured the laparoscopic view and prohibited its simultaneous use. With CO2 colonoscopy, combined laparoscopic and endoscopic procedures can be performed simultaneously and may have many potential applications, including the management of benign colonic polyps that are not removable by traditional endoscopic techniques. These polyps often require a colectomy because of the risk that they harbor cancer within them, as well as the future risk of developing cancer. However, an alternative approach in this setting may be a combined laparoscopic and CO2 colonoscopic polypectomy. When these procedures are combined, a polyp can be removed without a formal bowel resection. This combined procedure allows for both intra- and extraluminal manipulation of the bowel wall to aid in endoscopic polyp removal (Figure 6). If the frozen section is found to be benign, the procedure is completed. However, if cancer is suspected, a formal laparoscopic colectomy can be performed. Any full-thickness injury to the bowel wall during endoscopic polyp removal is visualized at the time of surgery and can be managed laparoscopically.

Conclusion

The use of minimally invasive approaches in the surgical management of colorectal diseases continues to gain popularity. Laparoscopy has clear advantages and can be performed in a majority of patients at surgical centers with experienced surgeons. Use of hand-assist devices and CO2 colonoscopy are essential tools in the operating room. As technology marches forward, newer techniques will continue to advance the quality of patient care.