Laparoscopic surgery, since the beginning of ‘90s, has gained an important place in management of oncologic diseases. Diagnostic laparoscopy is an important tool in staging of neoplasms, while operative laparoscopy has a double role both in radical and in palliative surgery.
The direct vision of laparoscopy in staging of abdominal neoplasms, compared with explorative laparotomy, gives the same informations about size of the mass, extension and possible infiltration of other adiacent structures (T, N). A first simple laparoscopic staging can be performed by washing the abdominal cavity with a saline solution: the cytologic exam of the liquid is often useful for the diagnosis of occult peritoneal carcinosis (M). Diagnostic laparoscopy can be operative too with a direct biopsy in case of abdominal suspected lesions. Laparoscopy’s sensitivity (96%) is higher respect to CT and ultrasonography in diagnosis of hepatic and peritoneal secondarisms.
The well-known advantages of laparoscopy, like the rapid recovery, the short hospital stay, the faster post-operative food resumption and bowel canalization and finally the reduced post-operative pain are joined, in these compromised patients, with a preserved immunologic response. A good staging of neoplasms reduces the number of “white laparothomy”, avoiding disconfort, pain and trauma in already compromised patients. Particularly, the rapid recovery plays an important role in a perspective of neoadjuvant chemotherapy.
In mini-invasive surgery of pancreatic neoplasms, pancreatic laparoscopic resections are reserved to a few number of specialized centres; nowadays laparoscopic duodenocephalopancreasectomy is considered a sperimental procedure because of the high incidence of complications and laparotomic conversion (40%). In literature are described hepatic, peritoneal and omental micrometastases in pancreatic adenocarcinomas considered as resectable; these secondarisms were not described by the conventional diagnostic, but were revealed at laparoscopy.
Very few advanced trained centers, actually, treat hepatic malignant diseases with laparoscopy, mainly for the requirement of an advanced tecnology ( intraoperative laparoscopic ultrasonography and RF). The indications for surgery are HCC, with or without associated cirrhosis and especially the macroscopic, superficial hepatic secondarism.
In gastric cancer, laparoscopy’s sensitivity is 97%, accuracy is 99% and specificity is 95%; laparoscopic abdominal exploration complements CT and facilities detection and pathologic confirmation of CT occult M1 disease, particularly macrometastases on the peritoneal surface or in the liver.
Laparoscopy identifies CT-occult metastatic disease in 23% to 37% of patients. The National Comprehensive Cancer Network has integrated laparoscopy as part of recommended routine staging algorithm for patients with locoregional and selected advanced gastric cancers. Palliative mini-invasive surgery is achievable in 20-73% of cases, with a rapid recovery and food resumption for the patients and a lower pain do to the minimal trauma.
Laparoscopic splenectomy is a gold standard in staging Hodgkin disease and in primary spleen lymphoma; the only absolute restrictions to laparoscopic surgery are: megalic spleen with a diameter > 25 cm, diseases of coagulation and portal hypertension. Compared to open surgery, the advantages are the lower bleeding and reduced hospital stay.
Laparoscopic surgery is also recommended in adrenal incidentalomas, pheochromocytomas, single metastases, and benign neoplasms with a minimal diameter of 5 cm or growing masses with a starting size of 3 cm.
For the neoplastic diseases of the colon-rectum , a radical approach is possible as in the open surgery, performing left or right hemicolectomy, including laparoscopy-assisted Miles procedure (abdominoperineal resection). The review of literature shows a statistically significative difference between open versus laparoscopic surgery in stadium III: the better immunological response in this stage is important to reduce the spread of tumoral cells and to increase survival. An ideal application of laparoscopy is a cancer of small size, without lymph node infiltration and limited in extension to the muscular layer of the bowel.
Finally, abdominal mini invasive surgery proves to be safe and achievable in oncology, although it reveales some limitations, like the two-dimensional vision, the lack of handling and the poor accuracy on evaluation of critical tumor-vessel relationships. Laparoscopic ultrasonography has been proposed as a means to overcome some of these limitations and to improve the diagnostic yield.
G. Faillace, E. Rota,
M. Mazzilli, A. Bianca,
L. Bottero, E. Esposito,
A. Fantini, P. Premoli, G. Turra, M. Longoni.
P.O. “Città di Sesto San Giovanni”
U.O.C. di Chirurgia I
Sesto San Giovanni, Milan
Direttore: dott. M. Longoni
