Which approach is best for colon surgery?

Strong evidence supports the laparoscopic approach.

Evidence from randomized trials of open vs. laparoscopic cholecystectomy has clearly demonstrated less impairment and more rapid recovery of pulmonary function after laparoscopy. These results have been replicated with other surgical procedures, including colon surgery.

One of the clear advantages of minimally invasive surgery is the smaller scars that result. Many have dismissed the cosmetic advantages of smaller scars but overlooked the significant impact that small scars have on postoperative wound complications. Several procedures, including appendectomy, colectomy, and gastric bypass, boast level 1 evidence of reduced wound infections with laparoscopy.

A lower incidence of incisional hernia formation has further been shown by studies of laparoscopic gastric bypass (Ann. Surg. 2001;234:279-89) and colectomy (J. Am. Coll. Surg. 2003;197:177-81). The latter study also found a significant reduction in hospital readmission for small bowel obstruction with laparoscopy and a 51% reduction in the requirement for reoperation for these two complications.

To further compound this issue, one study found fewer complications associated with laparoscopic repair of ventral hernias that presumably arose from prior open surgery (Surg. Endosc. 2003;17:1778-80).

Perhaps the most compelling evidence comes from a recent meta-analysis of trials of laparoscopic vs. open colectomy (Colorect. Dis. 2006;8:375-88). This review of 17 prospective randomized clinical trials involving more than 4,000 procedures found a reduction in perioperative mortality associated with laparoscopy.

As for the impact of minimally invasive surgery on length of hospital stay, the benefits are clear with some procedures such as laparoscopic cholecystectomy, bariatric surgery, and antireflux surgery. The gains with laparoscopic colectomy have been more moderate, leading some to question the magnitude of this advantage.

Three meta-analyses of prospective randomized, controlled trials of laparoscopic vs. open colon surgery all concluded that laparoscopic colon surgery leads to a significant reduction in postoperative hospital stay (Cochrane Database of Systematic Reviews 2005; CD003145; Br. J. Surg. 2004;91:1111-24; Colorect. Dis. 2006;8:375-88). There is no higher level of scientific evidence that can be attained.

Debate regarding the clear advantage of laparoscopic surgery on length of hospitalization arises from the expanding body of work surrounding so-called fast-track surgery. It is clear that by modifying the perioperative care we deliver to our patients, by minimizing pain and other factors that incite the surgical stress response, and by releasing patients from the shackles of unnecessary tubes and drains, we can mitigate the trauma of surgery and reduce the need for hospitalization. There is yet no credible evidence that fast-track surgery alone can supplant the advantages of minimally invasive surgery. Laparoscopic surgery is just one very effective component of this multimodal care, and patients having laparoscopic procedures can also benefit from these interventions.

DR. SCHLACHTA is associate professor of surgery and oncology at the University of Western Ontario in London. He also serves as medical director of Canadian Surgical Technologies and Advanced Robotics.

CHRISTOPHER M. SCHLACHTA, M.D.

Open colectomy offers some distinct advantages.

Recent studies suggest that the hospital length of stay following laparoscopic colectomy ranges from 5 to 8 days. It is rare to find a length of stay shorter than 4 days, which is the common length of stay after open surgery, if critical pathways are used.

A randomized, blinded trial of 60 patients over age 55 who had anastomoses greater than 12 cm from the anus and underwent elective right or sigmoid resections found that the operative time was about 50% longer for laparoscopic vs. open surgery, but length of stay was shorter for patients who had open surgery (2.3 days vs. 2.9 days, respectively).

There were no differences between the two groups in terms of GI function, cardiopulmonary function, mental function, C-reactive protein levels, convalescence, or patient satisfaction (Ann. Surg. 2005;241:416-23).

Postoperative complications and outcomes have been compared in many papers. In a meta-analysis that included 2,512 patients from 12 randomized, controlled studies, there was no significant reduction in the rate of overall morbidity with laparoscopic vs. open surgery (Br. J. Surg. 2004;91:1111-24). The only difference found in local complications was that the wound infection rates were twice as high for the open cases, but these were uncontrolled for the use of wound protectors or other factors known to reduce the incidence of wound infection.

In the MRC CLASICC trial (Multicentre Randomised Clinical, Conventional Versus Laparoscopic-Assisted Surgery in Patients with Colorectal Cancer), mortality after open surgery was reported as 5%, compared with 1% after laparoscopic surgery (Lancet 2005;365:1718-26). However, among the 29 patients in the study who required conversion to open surgery, mortality rose to 9%.

There were no differences between the two groups in terms of intraoperative complications, postoperative complications at 30 or 90 days, 7-day transfusion requirements, or quality of life scores.

A recent meta-analysis of studies that assessed laparoscopic vs. open surgery for colorectal cancer found no difference in perioperative mortality (J. Am. Coll. Surg. 2007;204:291-307). The wound infection rate was 2.9% in the laparoscopic group vs. 4.4% in the open surgery group, but none of the studies was controlled for perioperative care.

Advantages of open colectomy include versatility, shorter operating time, efficiency, a shorter learning curve, lower cost, and greater safety.

The disadvantages would seem to be immunologic indicators, although the significance of findings in this field is completely unknown.

It is highly questionable whether the difference in incision size between laparoscopic vs. open colectomy (usually a 4-inch difference) translates into a meaningful clinical difference. It is probably more important to know what to do than to fuss about whether to do it open or laparoscopically or how long the incision is.

Reasons to avoid laparoscopic colon surgery are that it offers increased cost but little or no advantage to the patient, either oncologically in terms of perioperative care or in quality of life.

DR. BILLINGHAM is clinical professor in the department of surgery at the University of Washington, Seattle.

RICHARD P. BILLINGHAM, M.D.