Information about Lap vs Open Colorectal Resection by Dr Dhaval Mangukiya. Details of Factors compared, COST Trial, CLASSIC Trial, COLOR Trial, COREAN Trial, ALCCS Trial, Summary, SAGES Guidelines, https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/

1. Dr Dhaval Mangukiya

2.  Oncological outcomes
 Duration of post operative ileus
 Postoperative pain
 Length of hospital stay
 Cosmesis
 Cost of treatment
 Operative time
 Postoperative complications

9.  A noninferiority trial started in 1994 at 48
institutions and randomly assigned 872 patients
with adenocarcinoma of the colon to undergo
open or laparoscopically assisted colectomy
performed by credentialed surgeons. The median
follow-up was 4.4 years. The primary end point
was the time to tumor recurrence.
 Patients with known locally advanced disease
were not enrolled, and patients with
intraoperative evidence of locally advanced
disease underwent conversion to an open
resection to ensure proper tumor management.

10.  Randomised clinical trial in 794 patients with
colorectal cancer from 27 UK centres between
July 1996 and July 2002.
 Primary short-term endpoints were positivity
rates of circumferential and longitudinal
resection margins, proportion of Dukes' C2
tumours, and in-hospital mortality.

11.  Multicenter RCT conducted in 1248 patients
of colon cancer of Netherlands.
 The primary endpoint was cancer-free
survival 3 years after surgery. Secondary
outcomes were short-term morbidity and
mortality, number of positive resection
margins, local recurrence, port-site or
wound-site recurrence, metastasis, overall
survival, and blood loss during surgery.

12.  Multicenter RCT recruiting 170 patients in each
arm of mid-low rectal cancer after neodjuvant
chemoradiotherapy.
 Short-term outcomes assessed were involvement
of the circumferential resection margin,
macroscopic quality of the total mesorectal
excision specimen, number of harvested lymph
nodes, recovery of bowel function, perioperative
morbidity, postoperative pain, and quality of life.
Patients continue to be followed up for the
primary outcome (3-year disease-free survival).

13.  A total of 601 patients of Australia and New
Zealand with potentially curable colon cancer
were randomized to receive LCR or OCR.
 Primary endpoints were 5-year overall
survival, recurrence-free survival, and
freedom from recurrence rates, compared
using an intention-to-treat analysis.

14.  Three year disease-free and overall survival
rates for stages I, II, and III were similar in the
two groups.

15.  Five year survival rates and recurrence rates
were similar in the two groups.

16.  Lap colectomy cases had shorter length of stay
and less intensive care unit monitoring.
 Although lap colectomy patients (n = 424) had
fewer complications (21.5% versus 26.3%), lower
30-day mortality (3.3% versus 5.8%), and longer
median survival (6.6 versus 4.8 years) compared
with open colectomy patients (n = 27,012), after
propensity score matching these differences
disappeared.

17.  Laparoscopic-assisted right colectomy results
in less blood loss, a shorter length of hospital
stay and lower postoperative short-term
morbidity compared with ORC.

18.  Analysis of the outcomes of 6438 resections showed that the
conversion rate was 13.3% with a statistically significant
difference between studies with > 50 versus <50 attempted
resections (11.7 vs 16.5%; P<0.001).
 Laparoscopic resection took 27.6% (41 min) longer to carry out
than open resection.
 There was no significant difference between the two groups in
early mortality rates (1.2 vs 1.1%; P=0.787) or likelihood of re-
operation (2.3 vs 1.5%; P=0.319).
 Laparoscopic resection was associated with a lower morbidity
rate (24.05 vs 30.80%).
 Time until passage of first flatus, passage of a bowel motion,
tolerating oral fluids and a solid diet was 1.2-1.6 days (26 to
37%) shorter, measurements of pain and narcotic analgesic
requirements were 16-35% lower and hospital stay was 3.5 days
(18.8%) shorter following lap resection compared with open
resection.
 The two approaches were 99% similar in terms of adequacy of
oncological clearance.

19.  33 RCT comparing laparoscopically-assisted versus open surgery
for colorectal cancer were identified.
 No significant differences in the occurrence of incisional hernia,
reoperations for incisional hernia or reoperations for adhesions
were found .
 Rates of recurrence at the site of the primary tumor were similar.
 No differences in the occurrence of port-site/wound recurrences
were observed (P=0.16).
 Similar cancer-related mortality was found after laparoscopic
surgery compared to open surgery ( colon cancer: 5 RCT, 1575
pts, 14.6% vs 16.4%; OR (fixed) 0.80 (95% CI 0.61 to 1.06)
(P=0.15); rectal cancer: 3 RCT, 578 pts, 9.2% vs 10.0%; OR (fixed)
0.66 (95% CI 0.37 to 1.19) (P=0.16).
 Four studies were included in the meta-analyses on hazard ratios
for tumour recurrence in laparoscopic colorectal cancer surgery.
No significant difference in recurrence rate was observed
between laparoscopic and open surgery.

20. ADVANTAGES DISADVANTAGES
Shorter duration of post operative
ileus
Increased operative time
Lesser postoperative pain ? Increased cost
Better pulmonary functions Long learning curve
Improved cosmesis
Reduced hospital stay
Earlier introduction of diet

21.  Tumor localization
When approaching colon resection laparoscopically, every effort should be
made to localize the tumor preoperatively. Small lesions should be marked
endoscopically with permanent tattoos before surgery to maximize the
surgeon’s ability to identify the lesion. Surgeons should be prepared to use
colonoscopy intraoperatively if lesion localization is uncertain.
 Preparation for operation
We suggest that preoperative mechanical bowel preparation be used to
facilitate manipulation of the bowel during the laparoscopic approach and to
facilitate intraoperative colonoscopy when needed.
 Surgical Technique – Colon
We recommend that laparoscopic resection follow standard oncologic
principles: proximal ligation of the primary arterial supply to the segment
harboring the cancer, appropriate proximal and distal margins, and adequate
lymphadenectomy.
 Surgical Technique – Rectum
We recommend that laparoscopic resection for rectal cancer follow standard
oncologic principles: Adequate distal margin, ligation at the origin of the
arterial supply for the involved rectal segment, and mesorectal excision.

22.  Contiguous Organ Attachment
For locally advanced adherent colon and rectal tumors, an en bloc
resection is recommended. We suggest an open approach if a
laparoscopic en bloc resection cannot be performed adequately.
 Obstructing Colon Cancer (Right-sided)
We recommend that patients with an obstructing right or transverse
colon cancer undergo a right or extended right colectomy. The open
approach is required if the laparoscopic approach will not result in an
oncologically sound resection.
 Obstructing Colon Cancer (Left-sided)
We suggest that for patients with an obstructing left-sided colon cancer,
the procedure be individualized according to clinical factors. Colonic
stenting may increase the likelihood of completing a one-stage
procedure and may decrease the likelihood of an end colostomy.
 Prevention of Wound Complications
The use of a wound protector at the extraction site and the irrigation of
port sites and extraction site incisions may reduce abdominal wall
cancer recurrences.