The Development of Laparoscopic Colon Surgery:

Two Hundred and Twenty Consecutive Colon Resections
by
Joseph N. Michelotti, M.D., M.A., F.A.C.S.

Conversion rate: 0.5%    Complication rate: 0.5%    Length of stay: 2.8 days

In 1990, a handful of surgeons around the world, including this surgeon, independently developed and introduced advanced video laparoscopic techniques for a number of abdominal operations including colon resections. Resistance to this revolutionary technology was intense, not only from less progressive community surgeons and hospitals, but major academic centers as well, including those in nearby Chicago caught uninformed and unprepared for rapid community based advancements in a field formerly steeped in traditional methods and sometimes arrogant hierarchy. When laparoscopic colon surgery was introduced by this surgeon in 1991, the only support for his work came from Elgin Surgeons, Ltd., and a few discerning patients and primary care physicians in the greater Elgin area. As the transition from "open" to "laparoscopic" surgery proceeded, safety and efficacy were never compromised. In 1994, the American Society of Colon and Rectal Surgeons (ASCRS) had begun to accept the sea changes that were occurring throughout general surgery and called for a moratorium on laparoscopic colon resection for cancer while the Clinical Outcomes of Surgical Therapy (COST) Study Group completed a long term randomized trial. This surgeon was not a member of the ASCRS and by then had already accumulated a large enough experience in advanced laparoscopy to be convinced that "open v. laparoscopic" randomization of patients would not be in the best interest of the patients randomized to "open" operations. The COST study was published in 2002. Sixty six surgeons performed 872 colon resections at 48 institutions. The mean number of nodes removed was 12. The percentage of patients who had their operations started laparoscopically, but had the technique abandoned and were converted to open operations (the conversion rate), was 21%. The average length of stay in the hospital (LOS) was 5.1 days for the laparoscopic operations and 6.4 days for the open operations. The study concluded that laparoscopic colon resection was safe and effective for the treatment of colon cancer, with the caveat that the operations must be performed by surgeons experienced in advanced laparoscopic techniques. Also, since the study was published there has been increasing academic consensus (the validity of which is debatable) that colon cancer patients should have 12 nodes examined. Nevertheless, a recent review showed that neither academic medical centers nor community hospitals frequently examine 12 or more nodes in node negative colon cancer patients. This list of consecutive cases by a single surgeon includes 200 colon operations during the transition from "open" to "laparoscopic" technique, and for the purpose of comparison there are also listed the 20 colon resections performed immediately before the transition began. The mean age of the patients was 73 years.

Among the 200 patients listed there are 106 men and 94 women. Most of the operations (151) were elective, but 28 were urgent and 21 were emergent. One hundred and sixty four cases were completed laparoscopically while 35 were planned and performed open, and only one was converted from laparoscopic to open. Our conversion rate of 0.5% is lower than any conversion rate reported to date, anywhere, and speaks to the reliability of our technique, and our persistent and patient application of it. Average blood loss was considerably lower for laparoscopic operations (97 ml) in comparison to open operations (338 ml). The length of stay (LOS) started at 4.9 days (already better than the COST Study) but improved dramatically after the first 25 cases to 2.8 days. In 2007, a US series of 62 cases in a community hospital reported a LOS of 4 days (lower than most larger hospitals) and in 2008 a large French study of 178 cases reported a LOS of 8 days. Our LOS of 2.8 days in a patient population as old as ours is exceptional, particularly when one considers that the average LOS for all colon resections performed at the same hospitals during the same time period was 7.2 days. One hundred and thirty two patients in the series of 200 patients had surgery for colon cancer (Stage 0 = 8; Stage 1 = 35; Stage 2 = 25; Stage 3 = 37; Stage 4 = 27). The average tumor size was 4.6 cm with the largest tumor in this series measuring 14 cm. This series took place long before any emphasis on the number of nodes examined. Nonetheless, the average number of nodes examined was 11. Patients with negative nodes had an average of 9 nodes examined and patients with positive nodes had an average of 12 nodes examined. In the latter, the average number of positive nodes discovered was 3.4. The number of nodes examined proved very adequate. This 200 case series had 4 operative deaths (2%), all from myocardial infarction between 4 and 5 days after surgery. There were no wound infections (0.0%) and one anastomotic leak (0.5%) which did not require re-operation but prolonged the patient's hospital stay to 6 days. The 5 year mortality from all causes in the 200 case series was 38% and in the cancer patients was 43%. This speaks to the fragility of this population. The 5 year mortality from colon cancer was 24%. Of the 68 patients with Stage 0, 1 or 2 colon cancer, only 2 (2.9%) developed recurrence and died with disease before 5 years, while 8 of 37 Stage 3 patients (21.6%) and 18 of 27 Stage 4 patients (66.7%) had died of disease before 5 years. The transition from "open" to "laparoscopic" surgery in our practice was accomplished safely and successfully with exceptional measurable outcomes.

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