Right colectomy: is it a safe and feasible totally laparoscopic approach with transvaginal specimen extraction
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- Hottenrott, C. Surg Endosc (2011) 25: 1699. doi:10.1007/s00464-010-1422-2
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To the Editors,
One of most rapidly evolving fields of surgery attracting major attention from new surgeons and enjoying popularity among patients is laparoscopic surgery for gastrointestinal cancers and other solid tumors. Solid evidence from randomized controlled trials and metaanalyses has shown better short-term quality-of-life outcomes after laparoscopic surgery including earlier recovery, less pain, and a better cosmetic result than after open surgery for colon cancer, without any negative effect on oncologic outcome. As a result of this evidence, the minimally invasive approach has been expanded to include laparoscopic treatment for resectable rectal cancer, gastric cancer and other tumors [1–9].
Initially, extracorporeal anastomosis and minilaparotomy were the standard procedure in laparoscopic colectomy. As laparoscopic surgery goes fast forward, the next challenge for further improvement of patient outcome is a totally laparoscopic approach. Is the evidence for totally intracorporeal laparoscopic right colectomy sufficient for a wider clinical use?
To approach this question, McKenzie et al.  published the short-term outcomes for totally laparoscopic right colectomy with transvaginal specimen extraction in the August issue of Surgical Endoscopy. This study also was performed to bridge the gap between new techniques and clinical application as interest in natural orifice translumenal endosurgery (NOTES) continues to grow. Data for four consecutive patients were analyzed, and the protocol was approved by the institutional review board.
A four-trocar laparoscopic right colectomy with intracorporeal anastomosis was performed for cancer in two cases and for adenomatous polyp in two cases involving women with no prior pelvic surgery. The average operating time including transvaginal extraction was 212.25 min. No complications were associated with the colpotomy. The median hospital stay was 4.5 days. The mean specimen length was 27 cm, and the mean number of lymph nodes retrieved was 15.75. The authors concluded that the technique of totally laparoscopic right colectomy with transvaginal extraction appears to be safe and feasible.
Totally laparoscopic right colectomy with transvaginal extraction may reduce abdominal wall morbidity, hasten recovery and return to home or work, and improve aesthetic result. However, this technique should be considered as experimental, at least currently. Further large-scale studies are needed, with careful evaluation of short-term outcomes and long-term follow-up assessment of the impact that totally laparoscopic right hemicolectomy has on oncologic outcomes.
Despite difficulties, it appears that improvements in short-term outcomes, thanks to advances in laparoscopic or robotic surgery, are being more quickly translated into clinical practice than improvements in long-term oncologic outcomes. Indeed, it is not surprising considering the latest data showing that cancer development and metastasis is much more complicated than we have supposed . Indeed, for example, for colorectal cancer, recent advances with KRAS and BRAF mutation status for selection of patients to undergo treatment with anti-EGFR monoclonal antibodies such as cetuximab or panitumumab have been translated into a progression-free survival but not an overall survival benefit in the metastatic setting.
This finding raises the question whether these targeted agents will be able to improve overall survival in the adjuvant setting. Ongoing or new clinical trials probably will highlight this critical question . However, advances in cancer biology and molecular oncology and the advent of next-generation sequencing technology provide now promises for new strategies. A more in-depth understanding of molecular mechanisms underlying cancer initiation and progression through cancer genome sequencing may open the way for new robust biomarkers and novel targeted drugs. These biologic agents added to current standard therapeutics may improve the oncologic outcomes for patients with major cancers at various sites [13–33].
Christof Hottenrott has no conflicts of interest or financial ties to disclose.