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Staging Laparoscopy in Intra-Abdominal Cancers

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Abstract

Laparoscopy is useful in staging of abdominal malignancies. Staging laparoscopy can improve accuracy of staging, assess resectability, decrease unnecessary exploratory laparotomy and hospital stay in unresectable or metastatic disease. It can also help obtain biopsy samples and offer palliative treatments. Along with adjuncts like laparoscopic USG it can aid in detection of peritoneal, omental, liver, and lymphatic tumour spread which may be missed in radiographic studies. This chapter discusses the technique of performing staging laparoscopy and its role in abdominal malignancies.

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Author information

Authors and Affiliations

  1. Departments of General Surgery & Surgical Oncology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

    Sudhir Kumar Singh, Farhanul Huda, Rajkumar Kottayasamy Seenivasagam & Somprakas Basu

Authors
  1. Sudhir Kumar Singh
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  2. Farhanul Huda
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  3. Rajkumar Kottayasamy Seenivasagam
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  4. Somprakas Basu
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Editor information

Editors and Affiliations

  1. Department of Surgery, Lady Hardinge Medical College, New Delhi, India

    Deborshi Sharma

  2. Department of Surgery, Lady Hardinge Medical College, New Delhi, India

    Priya Hazrah

Editor’s Note

References: Main chapter references are included after the “References Editor’s Note” section.

Editor’s Note

Clinical staging of malignancies has been traditionally limited to non-operative techniques viz: history, physical examination, imaging and endoscopy. Staging laparoscopy until lately was not a recommended modality of clinical staging in malignancies, however recently its incorporation has been envisaged in selective patient subgroups.

Objective of staging laparoscopy: The main objective of staging laparoscopy is to assess resectability and rule out peritoneal, omental, superficial visceral and other intrabdominal metastasis which often eludes detection by current imaging modalities. In addition, it provides an opportunity to obtain tissue diagnosis from primary and metastatic lesions as also lymph node sampling particularly in situations where previous core biopsy was not possible or inconclusive. It also aids in evaluation of ascites in patients with malignancy. Any consequent upstaging of the disease can help avoid unnecessary laparotomy in borderline resectable cases or high-risk patients and procedures, thus minimizing morbidity and mortality. The relatively painless quick recovery after staging laparoscopy aids in early initiation of adjuvant/neoadjuvant treatment when compared with conventional laparotomy. Additionally, other surgical procedures like splenectomy and oopheropexy in lymphoma and insertion of an enteral tube for feeding or palliative procedures can be done when indicated. With the availability of adjuncts like laparoscopic ultrasound the diagnostic accuracy of detection of liver lesions has improved over and above other imaging techniques. Staging laparoscopy should be considered as an additional tool to help staging and not an alternative to high quality imaging.

Contraindication: Strong contraindications to use of staging laparoscopy are:

  1. 1.

    Patients unfit for general anaesthesia

  2. 2.

    Distant metastasis has been confirmed by imaging techniques and biopsy not necessary/available.

  3. 3.

    Dense intrabdominal adhesions

Other relative contraindications are patients in whom a laparotomy is indicated viz: Patients with early-stage malignancy or in advanced disease where a surgical palliation is essential (for example in intestinal obstruction or gastrointestinal haemorrhage), due to its lack of perceived benefits and non-metastatic borderline resectable tumours where upfront neoadjuvant chemotherapy is planned.

Disadvantages: The noted disadvantages are:

  1. 1.

    The inherent risks of laparoscopic access and pneumoperitoneum

  2. 2.

    Procedure- and anaesthesia-related complication

  3. 3.

    False negative results may lead to unnecessary laparotomy

  4. 4.

    When staging laparoscopy is planned in separate sitting then there may be a delay in definitive treatment

  5. 5.

    In situations where the yield is low it can add to unnecessary cost

  6. 6.

    Potential adverse oncologic effects of the procedure viz: peritoneal dissemination, port site inoculation, cyst rupture etc.

Opposition: Detractors of the procedure have put forth that with the availability of recent imaging techniques a high accuracy has been achieved in detection of distant metastasis and additional staging laparoscopy may be of limited benefit [1].

Adjuncts: Different Adjunctive techniques have been used to detect peritoneal hepatic and lymphnode metastasis as well as vascular invasion [2–6].

Adjuncts used in staging laparoscopy to increase yield

  1. 1.

    Laparoscopic USG

  2. 2.

    Lavage Cytology + RTPCR (e.g., for carcinoembryonic antigen)

  3. 3.

    Near Infra-red Fluorescence Laparoscopy/Indocyanine Green Fluorescence

  4. 4.

    Five aminolevulinic acid Fluorescence

  5. 5.

    Fluorescent antibody imaging

Though most studies on fluorescence laparoscopy reported are in experimental models’ literature in clinical scenariosare emerging.

Results of meta-analysis of trials evaluating staging laparoscopy in various abdominal malignancies have been tabulated in Table EN1 [7–16].

Table EN1 The results of trials evaluating staging laparoscopy in gastrointestinal and hepatobiliary and gynaecological malignancies [7–16]
Full size table

References for Editor’s notes

  1. 1.

    Guidelines for diagnostic laparoscopy. https://www.sages.org/publications/guidelines/guidelines-for-diagnostic-laparoscopy/.

  2. 2.

    Handgraaf HJM, Sibinga Mulder BG, ShahbaziFeshtali S, Boogerd LSF, van der Valk MJM, FariñaSarasqueta A, Swijnenburg RJ, Bonsing BA, Vahrmeijer AL, Mieog JSD. Staging laparoscopy with ultrasound and near-infrared fluorescence imaging to detect occult metastases of pancreatic and periampullary cancer. PLoS One. 2018;13(11):e0205960. https://doi.org/10.1371/journal.pone.0205960.

  3. 3.

    Murayama Y, Ichikawa D, Koizumi N, Komatsu S, Shiozaki A, Kuriu Y, Ikoma H, Kubota T, Nakanishi M, Harada Y, Fujiwara H, Okamoto K, Ochiai T, Kokuba Y, Takamatsu T, Otsuji E. Staging fluorescence laparoscopy for gastric cancer by using 5-aminolevulinic acid. Anticancer Res. 2012;32(12):5421–7.

  4. 4.

    Jamel S, Markar SR, Malietzis G, Acharya A, Athanasiou T, Hanna GB. Prognostic significance of peritoneal lavage cytology in staging gastric cancer: systematic review and meta-analysis. Gastric Cancer. 2018;21(1):10–8. https://doi.org/10.1007/s10120-017-0749-y.

  5. 5.

    Yoon H, Lee DH. New approaches to gastric cancer staging: beyond endoscopic ultrasound, computed tomography and positron emission tomography. World J Gastroenterol. 2014;20(38):13783–90. https://doi.org/10.3748/wjg.v20.i38.13783.

  6. 6.

    Shirakawa S, Toyama H, Kido M, Fukumoto T. A prospective single-center protocol for using near-infrared fluorescence imaging with indocyanine green during staging laparoscopy to detect small metastasis from pancreatic cancer. BMC Surg. 2019;19(1):165. https://doi.org/10.1186/s12893-019-0635-0.

  7. 7.

    Convie L, Thompson RJ, Kennedy R, Clements WD, Carey PD, Kennedy JA. The current role of staging laparoscopy in oesophagogastric cancer. Ann R Coll Surg Engl. 2015;97(2):146–50. https://doi.org/10.1308/003588414X14055925061270.

  8. 8.

    Ramos RF, Scalon FM, Scalon MM, Dias DI. Staging laparoscopy in gastric cancer to detect peritoneal metastases: a systematic review and meta-analysis. Eur J Surg Oncol. 2016;42(9):1315–21. https://doi.org/10.1016/j.ejso.2016.06.401.

  9. 9.

    Hariharan D, Constantinides VA, Froeling FE, Tekkis PP, Kocher HM. The role of laparoscopy and laparoscopic ultrasound in the preoperative staging of pancreatico-biliary cancers--a meta-analysis. Eur J Surg Oncol. 2010;36(10):941–8. https://doi.org/10.1016/j.ejso.2010.05.015.

  10. 10.

    Coelen RJ, Ruys AT, Besselink MG, Busch OR, van Gulik TM. Diagnostic accuracy of staging laparoscopy for detecting metastasized or locally advanced perihilar cholangiocarcinoma: a systematic review and meta-analysis. Surg Endosc. 2016;30(10):4163–73. https://doi.org/10.1007/s00464-016-4788-y.

  11. 11.

    Tian Y, Liu L, Yeolkar NV, Shen F, Li J, He Z. Diagnostic role of staging laparoscopy in a subset of biliary cancers: a meta-analysis. ANZ J Surg. 2017;87(1–2):22–7. https://doi.org/10.1111/ans.13762.

  12. 12.

    Ta R, O'Connor DB, Sulistijo A, Chung B, Conlon KC. The role of staging laparoscopy in resectable and borderline resectable pancreatic cancer: a systematic review and meta-analysis. Dig Surg. 2019;36(3):251–60. https://doi.org/10.1159/000488372.

  13. 13.

    Bastiaenen VP, Klaver CEL, Kok NFM, de Wilt JHW, de Hingh IHJT, Aalbers AGJ, Boerma D, Bremers AJA, Burger JWA, van Duyn EB, Evers P, van Grevenstein WMU, Hemmer PHJ, Madsen EVE, Snaebjornsson P, Tuynman JB, Wiezer MJ, Dijkgraaf MGW, van der Bilt JDW, Tanis PJ. Second and third look laparoscopy in pT4 colon cancer patients for early detection of peritoneal metastases; the COLOPEC 2 randomized multicentre trial. BMC Cancer. 2019;19(1):254. https://doi.org/10.1186/s12885-019-5408-8.

  14. 14.

    Park HJ, Kim DW, Yim GW, Nam EJ, Kim S, Kim YT. Staging laparoscopy for the management of early-stage ovarian cancer: a metaanalysis. Am J Obstet Gynecol. 2013;209(1):58.e1–8. https://doi.org/10.1016/j.ajog.2013.04.013.

  15. 15.

    Lu Y, Yao DS, Xu JH. Systematic review of laparoscopic comprehensive staging surgery in early stage ovarian cancer: a meta-analysis. Taiwan J Obstet Gynecol. 2015;54(1):29–38. https://doi.org/10.1016/j.tjog.2014.10.003.

  16. 16.

    Bogani G, Borghi C, Leone Roberti Maggiore U, Ditto A, Signorelli M, Martinelli F, Chiappa V, Lopez C, Sabatucci I, Scaffa C, Indini A, Ferrero S, Lorusso D, Raspagliesi F. Minimally invasive surgical staging in early-stage ovarian carcinoma: a systematic review and meta-analysis. J Minim Invasive Gynecol. 2017;24(4):552–62. https://doi.org/10.1016/j.jmig.2017.02.013.

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Singh, S.K., Huda, F., Seenivasagam, R.K., Basu, S. (2022). Staging Laparoscopy in Intra-Abdominal Cancers. In: Sharma, D., Hazrah, P. (eds) Recent Concepts in Minimal Access Surgery. Springer, Singapore. https://doi.org/10.1007/978-981-16-5473-2_10

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