Discovering the Possibilities:

Although laparoscopic techniques have recently made tremendous advances, the foundations of laparoscopy have been in existence for centuries. Even Hippocrates refers to the use of a speculum for examining hemorrhoids. During the last five hundred years, doctors have constructed complicated series of mirrors and candles to shed light on the problems of their gynecological patients.

Laparoscopy has multiple uses for carcinoma patients -- establishing a diagnosis of cancer, staging established malignancies, surgically treating malignancies, even performing services that are indirectly related to cancer: palliative care such as feeding-tube placement or intestinal stoma creation.¹

The precursors to the modern laparoscope were primarily employed for gynecological and gastroenterological purposes. Laparoscopes were used for diagnosis until the 1970s, when operative laparoscopy became possible with the development of sophisticated surgical tools and video equipment.

In the dawn of the twenty-first century, laparoscopy is becoming ever more popular as a tool for managing a host of surgical procedures. It is a less-painful, less-invasive option for many patients, and because of the more limited invasion, the rate of infection is lowered as well. The benefits of this procedure seem to make it well worth the increased cost. But what are its limitations? Has it become a sacred cow? And, if not, how (and when) does it apply today?

Limitations and Costs

Despite laparoscopy's benefits, there are limitations to the technique. First, the surgeon's sensory input is often restricted to a two-dimensional picture on a video screen, and the procedure is rarely performed in a surgeon-friendly position and lacks the tactile sensation that surgeons are accustomed to. Recently, however, technology has become available that offers three-dimensional vision and tactile sensation. The new developments bring dexterity back into the picture and allow surgery in "ergonomically acceptable conditions."²

Laparoscopy appears to be more expensive than traditional surgery -- at least, up front. But because hospital stays are generally shorter, and because there are generally fewer post-operative complications, the overall cost of laparoscopy can often be less than that of open surgery.

According to an article at the Miami Medical Alliance online, the true cost of laparoscopy has been difficult to measure. Michael Hellinger, MD, assistant professor and chief of the Division of Colon and Rectal Surgery at the University of Miami/Jackson Medical Center, says that although the surgery itself is more costly -- due to more sophisticated instrumentation, more throw-away equipment and more staplers -- a shorter hospital stay and recovery, and the intangible benefits of reduced pain, have to be factored in.

Even though costs also increase because of the lengthier procedure (paying for the additional time of the nurses, surgeons and anesthesiologists), the fact that the recovery period can be two weeks as opposed to two months is a powerful selling point, and may be worth much more to the patient than the amount printed on the hospital bill.³

A study published in the Archives of Pediatric and Adolescent Medicine in 1999 comes to a similar conclusion. In the retrospective review of all cases performed in a 36-month period, the cost surplus of the procedure was compared with the savings associated with a shorter hospital stay, resulting in the conclusion that laparoscopy is cost-effective, especially for fundoplications, appendectomy and cholecystectomy.⁴

But what about cancer specifically? Do the costs differ from laparoscopy as applied overall? In a retrospective analysis at the Women's Cancer Center of Northern California, the records of women with presumed early stage endometrial cancer were grouped according to the type of procedure used. The first group underwent exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic and aortic lymphadenectomy; the second group underwent the same surgery but by laparoscopy. Costs were classed by the following four types: operating room, hospital bed, pharmacy and anesthesia; and the quality of life was assessed according to average hospital stay, complications, and the time needed to return to normal activity.⁵

There was a significant difference in terms of hospital stay and the time to return to normal activity -- higher in the laparotomy group in both cases. The number of days hospitalized was nearly tripled in the laparotomy group, and the time necessary to return to normal activity was more than doubled. Due to the lengthier hospital stay, the costs were significantly higher for those patients who underwent laparotomy.

Clearly, this is not an isolated benefit. Most groups of patients -- as long as they meet the prerequisites of laparoscopy (a reasonable weight and general heart and lung health) -- can benefit in both tangible and intangible ways from the procedure.

Sacred Cows Make the Best Burgers

Despite its growing popularity, laparoscopy is not a cure-all for every surgical patient. There are indeed times when laparoscopy is contraindicated. Physicians of different specialties have different recommendations. One surgeon contraindicates laparoscopy (in general) in patients with increased intracranial pressure, or patients with ventricular or peritoneal shunts. Other patients who may not respond well to laparoscopy include those with congestive heart failure. Also, if patients have reduced left ventricular ejection fraction, invasive monitoring should be considered, and these patients should probably not be discharged on the same day.⁶

Colorectal Cancer

Specifically, laparoscopy in cases of colorectal cancer is not always recommended, first, because laparoscopy is technically difficult and requires operating over multiple quadrants; second, because it involves handling a large, bacteria-laden, potentially-malignant organ. Additionally, fears of port site tumor recurrence and inadequate lymphadenectomy has led many to wonder if laparoscopy is an "oncologically sound procedure" for use in this instance.⁷

Gynecological Cancer

Gynecological, prostate and testicular cancers are (lately) becoming popular targets for laparoscopy. The procedure is making great headway in both male and female reproductive carcinomas, with constant improvements and new applications.

But, as always, there are several contraindications to laparoscopy for gynecological cancers. One study of patients undergoing aortic and pelvic lymphadenectomy for surgical staging found that obesity is a major limiting factor in performing aortic lymph node dissections. For this procedure, the authors selected patients for laparoscopy based on a Quetelet index of 30 or less. They note that patients who have undergone previous surgery -- particularly retroperitoneal exploration -- and patients who have undergone whole pelvis radiation therapy will be more difficult surgically. And, the authors say, "Although adhesions alone might not prevent the completion of surgical staging, their existence may add significantly to operative time, morbidity and the frustration level of the operating surgeon."⁸

Carefully selecting patients and skilled surgeons, and utilizing the most up-to-date equipment, are crucial factors in effectively performing this technique. The authors point out the need for a prospective study comparing laparoscopy to laparotomy for these biopsies; the reduced pain, shorter hospital stay and quicker recovery are counterbalanced by longer operating times and greater surgical costs.

The benefits of laparoscopy in ovarian cancer, however, are more clear-cut. The removal of the ovaries by laparoscopy certainly offers less postoperative pain, shorter recovery times and excellent outcomes, but because the technique is difficult to master, many surgeons subscribe to the more conventional laparotomy.⁹ Of note, laparoscopy is contraindicated if advanced debulking is necessary.¹⁰

Testicular Cancer

Laparoscopy for testicular cancer has been limited, partly because of the learning curve associated with the procedure. The first stage I patients to undergo laparoscopic retroperitoneal lymphadenectomy were more prone to serious complications and conversion to open surgery because of bleeding. However, the complications and need for conversion to open surgery have been lessened with the acquired experience of the surgeon.¹¹

Only some -- not all -- patients may be managed best by laparoscopy. The authors suggest that noncompliant patients -- who are averse to adequate follow-up on a surveillance protocol -- interested in treatment with chemotherapy and laparoscopic retroperitoneal lymphadenectomy might be good candidates.

The laparoscopic technique has not been much tested, but more study may show that laparoscopic removal of low-volume teratoma after chemotherapy is equal in value to open retroperitoneal lymphadenectomy. But the authors stress patient selection, as scarring and reaction in the retroperitoneum is difficult to foresee via preoperative CT scan. Also, for the procedures to be equivalent therapeutically, the local recurrence rate in the retroperitoneum would have to be extremely low.

The authors conclude that the current use of laparoscopy to perform lymphadenectomy in testicular cancer patients is "nothing more than an expensive staging tool." Until there is evidence that the laparoscopic method is equivalent to standard retroperitoneal lymphadenectomy, they cannot recommend laparoscopy as a standard method of management.

Prostate Cancer

As with other specialties, urologists find laparoscopy technically demanding and time-consuming, so until recently, laparoscopy has not often been utilized to manage prostate cancer. But an FDA approval of new robotic instruments last summer is making laparoscopic radical prostatectomy possible. Since the traditional radical prostatectomy requires an incision at least 6 inches long, and because there is often a six-week recovery, impotence and incontinence, a kinder, less-invasive option has been needed for some time.¹²

Because the prostate is buried deep in the body, and because of profuse bleeding associated with open surgery, it can be difficult to visualize, and a laparoscopic approach is a boon. Although the technique will be limited for some time because of the learning curve, Mani Menon, MD, of Henry Ford Hospital's Vattikuti Urology Institute in Detroit predicts that in five to 10 years, prostate cancer surgery will have radically changed.

But an associate professor of surgery at the University of Michigan Medical Center does not foresee laparoscopy taking over conventional surgery quickly. Stuart Wolf, MD, expresses concern over good cancer control, and notes that laparoscopy has not yet been proven to have a significant advantage over open surgery.

A surgeon at Seattle's Harborview Medical Center has performed the laparoscopic procedure (minus the robotic instruments) 10 times. James Porter, MD, chief of urology at Harborview, has utilized laparoscopy many times, but has just recently added the laparoscopic prostatectomy to his repertoire -- with the added bonus of a voice-activated camera. This, he says, is essential because a person would have difficulty controlling the camera steadily for the six to eight hours of surgery. That six to eight hours is up to three times longer than open surgery, and the laparoscopic method may carry a slightly higher impotence rate, but again, that will most likely improve with experience.¹³

Although in some respects laparoscopy is still in its infancy, dedicated study and application can make this expensive procedure less costly, less time-consuming, and of potentially greater benefit than standard surgery.

In cases of caecal cancer or adhesive ileus, laparoscopy is contraindicated in patients who underwent many abdominal operations, patients with market flutter of the belly or paralytic ileus as indication to nasointestinal intubation.¹⁴

In primary adrenal cancer, laparoscopy is contraindicated if the large mass is infiltrating into peri-adrenal tissue or has adrenal vein or inferior vena cava thrombus.¹⁵

In kidney cancer, laparoscopy is contraindicated for patients with extensive surgical scarring or large kidney tumors.¹⁶

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