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Minimally Invasive Surgery for Colon Cancer
Mono- and multicenter RCTs (KOLOR, COST, CLASSIC-Trail) showed no differences between laparoscopic and open techniques in colon cancer surgery regarding surgical-oncological quality indicators (R-status, lymph node count) and long-term outcomes (tumor recurrences, survival) with appropriate expertise of the surgeon [1, 3, 4]. As an advantage of minimally invasive surgery, a relatively low perioperative morbidity with unchanged overall morbidity and mortality was demonstrated in the short term [9].
According to the current S3 guideline "Colorectal Cancer," a laparoscopic resection of colon cancer can be performed in suitable cases with the appropriate experience of the surgeon [8]. There is currently no data basis for the application of NOTES in colon cancer.
Laparoscopic colon resections are among the demanding procedures whose learning curve is only overcome after at least 88 resections [6]. The proportion of right-sided colon resections in carcinomas is currently relatively low at around 20% and is usually performed as a laparoscopically assisted resection, where anastomosis is performed extra-abdominally via a retrieval laparotomy.
SILS, NOTES, and Robotic
The further development of minimally invasive surgery pursues two main directions:
- further reduction of access trauma (SILS, NOTES)
- improvement of the precision of instrument guidance or preparation (Robotic)
A reduction of access trauma is possible with the SILS technique (Single Incision Laparoscopic Surgery), where, in contrast to conventional laparoscopy, the instruments are introduced through a single access point (Single-Port System). Another option is the NOTES technique (Natural Orifice Transluminal Endoscopic Surgery) using natural body openings for instrument introduction.
Regarding the technical feasibility and safety of single-port colon surgery, Makino et al reported in a systematic review as early as 2012 [5]. With adequate lymph node count and tumor-free specimen margins, adherence to oncological standards is theoretically possible with SILS. However, the present review emphasizes the highly selected patient population and the particular laparoscopic expertise of the surgeon. Regarding the anticipated cosmetic advantages, it must be conceded that the incision length in these procedures is generally determined by specimen retrieval rather than the port used.
There is currently no valid data basis for the application of NOTES in colon cancers.
The situation is different for robotic surgery of colon cancer. Case series show that robotic surgery can be safely applied in colon cancer and has advantages in terms of tissue preservation and reduction of postoperative functional disorders [2, 10]. In terms of short-term and especially oncological long-term results, robotic-assisted surgery for colon cancer cannot currently be recommended outside of studies due to insufficient data [7].