Medial Versus Lateral Approach for Laparoscopic Colectomy in Colorectal Cancer Surgery

doi:10.21203/rs.3.rs-954912/v1

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Medial Versus Lateral Approach for Laparoscopic Colectomy in Colorectal Cancer Surgery

https://doi.org/10.21203/rs.3.rs-954912/v1

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Background: Colorectal cancer is considered the 3^rd common malignancy worldwide responsible for 9% of all cancer incidence. Currently laparoscopy is widely practiced in colorectal cancer surgery. It is related to the surgeon's experience to do either lateral-to-medial or medial-to-lateral approach. The two laparoscopic approaches are currently practiced and there are conflicts of superiority of this over that and vice versa.

We aimed to show the superiority of one procedure over the other regarding short-term outcomes.

Patient and Methods: This is a prospective randomized study of laparoscopic colorectal surgery. One hundred patients were included in this study.

Patients were divided to 2 equal groups medial to lateral (M-L) and lateral to medial group (L-M), 50 patients each. The study was conducted from Feb 2017 to May 2021 in Menoufia university hospital, in the general surgery department.

The study endpoint was: The feasibility, technical efficacy, operative time, vascular or ureteric injury and other complications of both techniques.

We collected data according to patient demographics, technique of laparoscopic mobilization, surgery duration, hospital stay, operative and post-operative complications and lymph node retrieval.

Results: One hundred patients with comparable demographics criteria had laparoscopic colorectal cancer surgery. Sixty-one patients were males (61%) and 39 patients (39%) were females. Fifty patients (50 %) were performed using M-L technique and the other 50 patients (50.0%) were operated upon using the L-M approach. Lateral approach had an average 10±3 (4–22) lymph nodes with specimen compared to 17±4 (9–31) in the medial approach. There was no statistically significant difference in the major complication rate (Clavien-Dindo IV) between the two approaches. M-L approach showed significant shorter operative time than L-M approach in anterior resection and Rt hemicolectomy in favor of M-L approach p<0.05. L-M approach showed a significant higher rate of conversion to open surgery and injury to the ureter and gonadal vessels. p<0.05. Patients in the M-L approach had a mean hospital stay of 5±1 days (range 3–52) compared to 5± 2 days (range 3–56) in the L-M approach. P >0.05

Conclusion: Both approaches were feasible for colon cancer surgery. Laparoscopic M-L approach was found technically easier, and had less surgery related complications than the L-M approach.

Surgery

Oncology

Colorectal cancer

Laparoscopic medial approach for colon cancer

laparoscopic colectomy.

Colorectal cancer is considered the 3rd common malignancy worldwide responsible for 9% of all cancer incidence [1]. The laparoscopic approach for colorectal surgery is increasing since first described in 1991 [2, 3]. Compared to the open approach, laparoscopic colorectal approach has improved the short-term outcomes including faster recovery, decreased period of post-operative ileus, decreased wound infection incidence, decreased hospital stays, lower postoperative pain and earlier tolerance of normal diet [3–10]. There’s no difference in recurrence rates, oncological clearance, complication rates, or re-operation rate between both approaches [4, 6, 8, 11]. This demonstrates the safety, feasibility and short-term benefits of the laparoscopic surgery.

Some authors reported that laparoscopic surgery is technically demanding, with a prolonged learning curve [12] and associated with a considerable length of operation time compared to open approach [8].

Mobilization of the colon laparoscopically can follow one of two ways. The (L-M) approach and (M-L) approach that was developed by Milsom and colleagues [13, 14].

The M-L approach for mesocolonic dissection was recommended by The European Association of Endoscopic Surgeons (EAES) consensus statement in 2004 recommended [15]. However, few published studies evaluated the comparative efficacy between the two approaches.

In the current study, we aimed to compare the M-L versus L-M approach during laparoscopic mesocolon dissection for colon cancer as regards feasibility, technical efficacy, operative time, vascular or ureteric injury, conversion to open surgery and other complications in both techniques.

This is a prospective comparative randomized study which was held in Menoufia university hospitals. The study was approved by the Minoufia faculty of medicine ethical committee. The study was conducted on 100 patients with colonic cancer and it was held in Feb 2017 to May 2021. All patients were discussed perioperatively by consultants in a multidisciplinary meeting and proven to have colorectal cancer which is indicated for surgery.

Data was collected on patient demographics, method of laparoscopic mobilization, intent of procedure, site of tumor, stage of tumor, operating time, hospital stay, conversion to open surgery, post-operative complications and lymph node retrieval.

* Participants were followed up for one year.

Inclusion Criteria

Patients aged 18 to 70 years old with confirmed colorectal cancer diagnosis by histopathology and had laparoscopic surgery with curative intent.

Exclusion Criteria

* Those under 18 or over 70 years.

Those undergoing non-cancer resections, open operations or completion surgery or palliative procedures.

* Those with locally advanced or metastatic tumors.

* Those with advanced comorbidities.

* Those with previous abdominal surgery with hostile abdomen.

Surgical Technique

All patients underwent laparoscopic surgery of the colorectal cancer and the colon was initially mobilized either laterally or medially. In M-L group, a mesenteric window is opened using cautery and blunt dissection is used to separate the congenital fusion plane between the mesentery and the retroperitoneum. In contrary in the L-M group, dissection started at the white line of Toldt. All patients had stapled intra-corporeal ileo-colic, colorectal anastomosis or terminal colostomy. Handsewn sutures were sometimes used for completion of the stapled intracorporeal anastomosis. Illustrative figures are shown in Figs. 1-7.

Data analysis

Data was analyzed using SPSS 24.0 (IBM SPSS Inc. Armonk, NY, USA). Comparisons between groups were made using chi-square test or fisher's exact test as appropriate. Results were extrapolated in box and whisker plot. p-value < 0.05 was considered significant.

One hundred patients had laparoscopic colonic resection during the study period.

Overall, 61 (61%) were male with a mean age of 55± 4 years (Range 33–70 years) (Tables 1,2). Fifty patients (50.0%) had surgery with M-L approach. Fifty (50.0%) had L-M approach. 63 (63%) patients had left sided surgery. 37 (37%) patients underwent right sided surgery.

Table 1

Patient characteristics
	Total	Medial	Lateral	P
Total	100	50	50	n/s
Male	61	28	33	n/s
Female	39	22	17	n/s

Table 2

Operative details
Procedure	Total no.	Medial	Lateral
Right Hemi-colectomy	37	19	18
Left Hemi-colectomy	33	17	16
Anterior Resection	30	14	16

Operative Time

The mean duration of Rt hemi-colectomy (37) in the M-L group was 186± 18 (95-195) minutes while L-M group was 217±26 (118-285) (Table 3). Left Hemi-colectomy (33) took190±17 (130-310) minutes in the M-L group compared to 200±19 (183-265) minutes in the L-M, p<0.05. The mean operative time anterior resections (30) was 220 ±27 (150-355) minutes in the M-L group compared to 245±29 (160-340) minutes in the lateral-to-medial group. p >0.05.

The Number Of Working And Assistant Ports:

Three to four ports were used in M-L group with a mean of 3±1, on the other hand, 4-6 ports were required in the L-M groups with a mean of 4±1. p<0.05

No significant differences were identified between the two groups as regards to age but there was male gender predominance of the whole number of patients. p<0.05. But there was no significant difference in the type of approach in both genders. p<0.05.

Table 3

Operating times and number of ports
Procedure	M-L Op time (mins)	L-M Op time (mins)	p
Right Hemi-colectomy	186±18 (95-195)	217±26 (118-285)	<0.05
Left Hemi-colectomy	190±17 (130-310)	200±19 (183-265)	>0.05
Anterior Resection	220 ±27 (150-355)	245± 29(160-340)	>0.05
Number of ports	3-4	4-5	<0.05

Lymph Node Retrieval

The mean number of LNs. dissected in M-L group were 17±4 (9–31) compared to 10±3 (4–22) in the L-M group. There was significant difference between the two groups. p <0.05.

Complications

Individual complication rates are summarized in (Table 4). Two patients (4%) had wound infection in the M-L group compared to three (6%) of patients in the L-M group. One (2%) patient in the M-L and similarly one patient (2%) patients within the L-M group had an anastomotic leak. One patient (2%) within the M-L group required reoperation while two (4%) patients had reoperations within the L-M group. One patient (2%) underwent conversion to open surgery in M-L group while three patients (6%) underwent conversion to open surgery in the L-M group.

Table 4

Complications
	M-L	L-M	P
Wound complications	2 (4 %)	3 (6%)	n/s
Re-operation	1 (2%)	2 (4%)	n/s
Anastomotic leak	1 (2%)	1 (2%)	n/s
Ileus	2 (4%)	4 (8%)	<0.05
Conversion to open approach	1 (2%)	3 (6%)	<0.05
Post-operative death	0	0	n/s
Length of stay (days)	5± 1(3-52)	5± 12(3-56)	n/s
Injury to gonadal vessels (Bleeding)	0 %	3 (6%)	<0.05
Injury to the ureter	0 %	1 (2%)	<0.05

Table 5

Clavien-Dindo grading of complications
Grade	Medial	Lateral	P
I	4 (8%)	6 (12%)	<0.05
II	5(10%)	6(12%)	<0.05
III	1 (2%)	3 (6%)	<0.05
IV	0 %s	0 %	n/s
V	0 %	0 %	n/s

There were statistically significant higher complications in favor of L-M approach. Delayed bowel movement, ureteric injury, conversion to open surgery, operative bleeding (injury to gonadal vessels) was more evident in L-M groups. p <0.05 (Table 4). The postoperative complications were classified according to the Clavien-Dindo classification (Table 5). There was statistically significant difference in grade I,II and III complications and no mortality was reported or major complication in either group.

Hospital Stay

Patients in both groups had similar hospital stay. Patients in the M-L group had a mean length-of-stay of 5±1 days (range 3–52) compared to 5±2 days (range 3–56) in the L-M group.

Colorectal surgery is an everyday practice worldwide. As a minimal access surgery, Laparoscopic colorectal surgery is associated with less post-operative pain, early oral diet tolerance, decreased postoperative ileus and faster recovery. Compared to open surgery, laparoscopic colorectal surgery is technically challenging, needs a long learning curve, requires special equipment and expensive consumables. These potential obstacles make surgeons reluctant to adopt laparoscopic colorectal techniques. Studies did not find superiority of open surgery regarding overall survival, oncological clearance, rate of recurrence, complication rates, and reoperation rate [11]. The two laparoscopic approaches are practiced nowadays and there are conflicts of preference for this over that and vice versa.

In the present study we found that the intraoperative bleeding and the rate of conversion to open surgery were significantly higher in the L-M group. p<0.05 (Table 4).

There was no significant difference as regards anastomotic leak, there was no significant difference as regards wound infection.

In addition, no statistically significant difference was found as regards operative time between the two approaches except for M-L Rt hemicolectomy, where it had significant shorter operative time p <0.05. Additionally, there was significant difference in the number of the retrieved lymph nodes in favor of M-L group. p <0.05 The increased number of retrieved lymph nodes in favor of M-L group expresses a better meso-colonic nodal clearance and a better curability and low rate of recurrence.

A meta-analysis by Ding and colleagues demonstrated increased benefits for M-L approach by studying 5 cohort studies including 2 randomized control trials and three retrospective studies including 881 patients [16–20]. They reported a lower conversion rate for M-L group, as well as significantly shorter operative duration and lower blood loss although this approach led to fewer retrieved lymph nodes. Moreover, rates for post-operative complications, wound infection, anastomotic leak, recurrence, and mortality as well as length of hospitalization were not significantly different between the two approaches. The reasons for an increased conversion rate in the present study, include adhesions, which was greater on the lateral sides due to diverticulitis in the left side and previous appendicitis in the right side. So, the risk of injury retroperitoneal structures becomes higher. Medial-to-lateral approach may allow early identification of the meso-colonic-retroperitoneal plane, with reduced blood loss. Another disadvantage of the lateral-to-medial approach includes higher redundancy of the colon, where manipulation of the colon becomes more difficult where a need to use an extra assistant port in most cases was required. The lateral peritoneal attachment makes the medial mesenteric dissection easier by applying counter-traction by the operating surgeon with no need to add an assistant port to pull the colon. Again we agree with Seif El-Deen et al that early control of the vascular pedicles can reduce bleeding and postoperative complications [21]. Anwar Hussain et al reported no significant difference in their retrospective study [22]. In contrary we found that the post operative ileus was lesser in favor of M-L group. p<0.05. One more benefit of the M-L approach in the present study, it allows early vascular control and pealing the LN away from the inferior mesenteric a. and the ileocolic a. hence, the incomplete clearance may decrease the survival and increase the possibility of metastasis and cancer recurrences. Earlier identification of the ureter and vessels of the gonads - during medial-to-lateral approach - prevented their injury and intraoperative bleeding. On the contrary, two patients in the present study suffered injury to the gonadal vessels on either side during the L-M. We followed up those patients for 6 months and we found no decrease in the testicular size or vascularity by ultrasound and MRI.

The present study encourages more application of medial-to-lateral approach in laparoscopic colorectal cancer surgery and more studies are needed from our colleagues to build solid evidence about the superiority of one technique over the other.

Despite laparoscopic medial-to-lateral and lateral-to-medial approaches were successful in meso-colonic resection during colorectal cancers. Laparoscopic medial-to-lateral approach was found safer, achieved more meso-colonic LN retrieval and had less surgery related complications than the lateral-to-medial approach. More studies are required from colleagues to build solid evidence of the efficiency, safety and superiority of one approach over the other for laparoscopic colorectal cancer surgery.

Despite the sample size was statistically calculated and approved by statisticians but we recommend a larger number of patients in future studies to build solid clinical evidence of both techniques.

Ethics approval:

The study was approved by the the institution Research Ethics Committee of the Minoufia Faculty of medicine, Minoufia university. This study was performed in accordance with the Declaration of Helsinki, and written informed consent was obtained from each patient before surgery.

Consent to participate in the study :

Patients informed consent was taken from all participants.

Consent for publication :

Consent for publication was taken from all participants

Availability of data and materials:

The data sets used and/or analyzed during the present study are available from the corresponding author on reasonable request.

Competing interest:

The authors declare that they have no competing interest.

Funding:

The authors declare that they didn’t receive any financial support for the research, or publications of this article.

Authors’ contributions:

Abou-Ashour H adopt the idea, all authors performed the surgeries Abou-Ashour wrote and revised the manuscript. Abou-Ashour, Elsisi, A. Shahin M and Moustafa A shared substantial contributions to the conception of the work and revision for critically important intellectual content. All authors read and approved the final manuscript.

Acknowledgements:

All gratitude is expressed to our patients our late professors, nurse, technicians who assisted us in our work.

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Medial Versus Lateral Approach for Laparoscopic Colectomy in Colorectal Cancer Surgery

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Abstract

Figures

Introduction

Materials And Methods

Inclusion Criteria

Exclusion Criteria

Surgical Technique

Data analysis

Results

Operative Time

The Number Of Working And Assistant Ports:

Lymph Node Retrieval

Complications

Hospital Stay

Discussion

Conclusion

Study Limitation

Declarations

References

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