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Hybrid Procedure Results

Long Term Survival After Hybrid Laparoscopic / Open Resection Method for Rectal Cancer

Richard L. Whelan, MD, C.C.C.N.Y., Chief Colon and Rectal Surgery at St. Luke’s Roosevelt Hospital


Although the use of minimally invasive surgical (MIS) methods for the resection of colon cancer has been well studied and accepted there is less data available regarding MIS rectal cancer resection methods. Rectal resections, the vast majority of which are done to remove a cancer, are more complex and demanding operations. Presently, several multicenter randomized trials comparing the traditional (large incision) and MIS methods are underway, however, the long term cancer survival and recurrence results are not yet available. Thus, it has not yet been proven that the long term outcome after MIS rectal resection is comparable to “open” (large incision) resection results. Critics worry that MIS rectal resections may be less thorough or radical than the “open” operation.


There are a number of different MIS rectal resection methods that have been introduced including laparoscopic, laparoscopic-assisted, hand-assisted laparoscopic, and “hybrid” laparoscopic / open methods. The goal of all of these methods is to minimize the size of the abdominal wall incision used to remove the cancer. Dr. Richard L. Whelan, the chief of colorectal surgery at CCCNY’s St. Luke’s Roosevelt Hospital and other colorectal surgeons in New York City embraced the MIS “hybrid” laparoscopic / open method rectal resection method in the late 1990’s. Recently, the survival results of 131 patients who underwent these hybrid rectal cancer resections have been determined and the results reported in a paper submitted for publication.


The standard “open” rectal resection requires a vertical incision in the middle of the abdomen that is usually 8 to 12 inches in length. In contrast, the hybrid laparoscopic / open approach removes the rectal cancer using a combination of open and laparoscopic methods. The laparoscopic part of the operation is done first via four or five 1/4 to ¾ inch incisions after which the procedure is completed using “open” methods through a 3 to 4 inch long incision located below the belly button. A good deal of the mobilization (freeing up) of the rectum from the surrounding tissues, the removal of the rectal segment containing the tumor, and the reconnection of the remaining bowel ends is done through the open incision. In a previously published study about the hybrid rectal resection method, Dr. Whelan’s team noted that the final hybrid incision was, on average, a little more than 3 inches long as opposed to 6 ½ inches long after open rectal resection.1 The thoroughness of the cancer resection, in regards to the number of lymph nodes and the size of the specimen removed were similar for the 2 methods. Of note, the hybrid patients had their first BM and were discharged from the hospital significantly sooner than the open rectal resection patients.


As mentioned, the long term results of 131 hybrid rectal cancer resection patients have recently been determined. After an average follow-up of 5.2 years the mean overall survival (includes alive patients with and without recurrent cancer) was 76 percent. In addition, the disease free survival was 70 percent which is better than the 64 % figure reported by the National Cancer Institute’s “Surveillance Epidemiology End Report” (SEER) data base. Thus, these results suggest that the hybrid laparoscopic / open MIS rectal resection method is safe and associated with long term survival rates, at least, as good as those following the standard open approach.


Of note, Dr. Whelan, in addition to the hybrid method now also uses the laparoscopic-assisted and hand-assisted laparoscopic methods for rectal cancers. These latter methods are associated with incisions 2 to 4 inches in length. It is important to realize that although some surgeons remain skeptical about MIS rectal resection methods, many experienced surgeons believe they are the best surgical method. The intermediate cancer outcome results from a large randomized trial comparing laparoscopic-assisted and open rectal resection are due to be released soon.


Reference


1. Vithianathan S, Cooper Z, Betten K, et al. Hybrid Laparoscopic Flexure Takedown and Open Procedure for Rectal Resection is Associated with Significantly Shorter Length of Stay than Equivalent Open Resection. Diseases of the Colon and Rectum 2001; 44(7): 927-35.

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