Laparoscopic Approach to Obstructive Colon Cancer: What Are the Options?

Morris E Franklin, JR, MD FACS, Karla Russek, MD, Daniel Davila, MD. Texas Endosurgery Institute

Introduction:
Most centers consider malignant colonic obstruction a contraindication to perform laparoscopic surgery, and, in clinical practice guidelines the recommendations are limited to patients who do not have colon cancer associated with perforation, obstruction, fistula or are locally advanced. Trials that have compared laparoscopically assisted and open colectomy for colon cancer have excluded patients with colonic obstruction as those that analyze the outcomes, especially survival, using the laparoscopic approach.
Material and methods: The objective of this study is to report our experience with patients presenting to the emergency department with bowel obstruction due to colon cancer. We designed a nonrandomized prospective study of all consecutive patients with obstructive colonic tumors. We recollected data from April 1992 to August 2009. Our aim is to describe the technique and present the results of our experience.
Results: From January 1991 to August 2009 we recollected data of 1262 colonic surgery cases, 636 with the diagnosis of cancer and 49 presenting with obstruction, which underwent laparoscopic approach.
2 surgeries were completed totally laparoscopically, 27 laparoscopically assisted and 17 were converted to open surgery. We performed 17 hemicolectomies for tumors located in the cecum (5 patients), ascending colon (7 patients), hepatic angle (4 patients) and transverse colon (1 patient); 2 left hemicolectomies; 13 sigmoid colectomies; 6 low anterior resections; 3 subtotal colectomies and 1 abdominoperineal resection. A resection was not performed in 4 patients due to advanced disease and a decompression and colostomy was successfully performed with laparoscopic technique in 3 of them, and one patient was converted to open surgery. 8 patients required a Hartmann procedure.
Discussion: Most conversions to open surgery were necessary in patients with prior abdominal surgery (7 cases), severe bowel distention, intraoperative complications (enterotomies) or severe metastatic disease or carcinomatosis. Even with this type of patients, laparoscopy offers the advantage of visualizing the exact localization of the intraabdominal process and the opportunity to perform a smaller and guided laparotomy incision.