Colonoscopy and other screening tests can detect colorectal cancer — the third most common cancer in the United States — at earlier stages than ever before, meaning more of these tumors can be removed using minimally invasive surgery.
Minimally invasive approaches differ from traditional open surgery in that they require only a few tiny incisions instead of one long one; for colon and rectal cancer patients, the options include laparoscopy and robotic surgery. Both techniques allow surgeons to remove tumors using a camera and surgical instruments inserted into keyhole-size incisions. Robotic surgery offers a three-dimensional view of organs and is believed to be more precise in experienced hands.
Memorial Sloan Kettering is the largest center in the Northeast for all types of minimally invasive colorectal surgery, and in 2013 led the nation in sheer volume of robotic colon and rectal surgeries, with more than 250 performed.
We asked Julio Garcia-Aguilar, Chief of the Colorectal Service in Memorial Sloan Kettering’s Department of Surgery, to describe the differences between laparoscopy and robotic surgery and to explain which patients are the best candidates for these procedures.
For Colon Cancer, Laparoscopy Proven Effective
Since its introduction about 20 years ago, laparoscopic surgery for colon cancer has consistently shown long-term survival rates comparable to open surgery.
Dr. Garcia-Aguilar credits greater use of screening colonoscopy for the increased detection of smaller colon tumors, which are more easily removed laparoscopically than advanced lesions that have spread beyond the colon to surrounding organs or structures. Colonoscopy use over the past decade has tripled among those aged 50 to 75, to 55 percent in 2010, according to the American Cancer Society.
“Most colon cancers today can be removed laparoscopically,” says Dr. Garcia-Aguilar. “Patients with tumors that are locally advanced or too large might not be the best candidates for a laparoscopic approach and may need open surgery. But today most colon cancers are diagnosed when they’re still localized and potentially removable using minimally invasive techniques.”
Using laparoscopy for rectal cancer is more challenging compared with colon cancer because of the rectum’s location in the bony pelvis, Dr. Garcia-Aguilar notes. But, as with colon cancer, patients with rectal tumors are typically considered for laparoscopic surgery if the cancer hasn’t spread beyond the rectum itself.
Robotic Surgery Offers 3-D View
Robotic surgery is similar to laparoscopy, but instead of the surgeon’s hands directly controlling the instruments, robotic arms are attached to the camera and surgical tools. The surgeon views a highly magnified, three-dimensional image of the patient’s organs while using finger controls to maneuver the instruments.
The robotic technique hasn’t been around for as many years as laparoscopy, Dr. Garcia-Aguilar says, but newer add-on “gadgetry” has adapted the equipment well for colorectal cancers.
“Initially the robot was used mainly to remove tumors in the rectum, and we only recently have been applying it to the colon,” he says. “Laparoscopy is like operating using long chopsticks, but robotic surgery is more precise, and is probably a more sophisticated way of doing minimally invasive surgery.”
Dr. Garcia-Aguilar acknowledges that a surgeon’s experience with the technique is critical to its success. All six colorectal surgeons at Memorial Sloan Kettering are trained to perform robotic surgery in addition to the laparoscopic approach, he says.
“We can’t claim right now that robotic surgery is better than laparoscopy because most operations are still performed open or laparoscopically,” he adds. “We have not operated on enough patients with the robot to compare the results with patients treated laparoscopically. My personal opinion, however, is that it’s a better way to perform minimally invasive surgery.”
Many Benefits to Minimally Invasive Approach
With a recurrence rate equal to that of open surgery and a thorough selection process to identify the best patients for minimally invasive colorectal surgery, Dr. Garcia-Aguilar says he sees no drawbacks to the approach.
The use of several small incisions instead of a single large one means less blood loss and postoperative pain for patients, as well as shorter hospital stays and lower infection rates. Additionally, patients undergoing minimally invasive surgery have a lower risk of abdominal hernia and a better cosmetic result, Dr. Garcia-Aguilar says.
“Laparoscopy is also probably more cost effective compared to open surgery because the higher cost of using special equipment in the operating room is offset by the patient’s faster recovery,” he says. “We suspect the same is true of robotic surgery. The benefits of minimally invasive surgery are real.”