Feasibility of purely laparoscopic resection of locally advanced rectal cancer in obese patients
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WORLD JOURNAL OF SURGICAL ONCOLOGY
RESEARCH
Open Access
Feasibility of purely laparoscopic resection of locally advanced rectal cancer in obese patients Tolutope Oyasiji1,2, Keith Baldwin1, Steven C Katz1, N Joseph Espat1 and Ponnandai Somasundar1*
Abstract Background: Totally laparoscopic (without hand-assist) resection for rectal cancer continues to evolve, and both obesity and locally advanced disease are perceived to add to the complexity of these procedures. There is a paucity of data on the impact of obesity on perioperative and oncologic outcomes for totally-laparoscopic rectal cancer resection (TLRR) for locally advanced disease. Methods: In order to identify potential limitations of TLRR, a single-institution database was queried and identified 26 patients that underwent TLRR for locally advanced rectal cancers (T3/T4) over a three-year period. Patients were classified as normal-weight (NW, body mass index (BMI) = 18.5 to 24.9 kg/m2), overweight (OW, BMI = 25 to 29.9 kg/m2) and obese (OB, BMI >/= 30 kg/m2). Perioperative outcomes, lymph node harvest and margin status were assessed. Results: Seven patients were classified as NW (26.9%), 12 as OW (46.2%) and 7 as OB (26.9%). Age, tumor stage, gender and American Society of Anesthesiologists (ASA) scores were similar. OB had more co-morbidities (median 3.0, range 0.0 to 5.0 vs. 2.0, range 0.0 to 3.0 for NW and 1.0, range 0.0 to 3.0 for OW). Five patients had tumors /= 30 kg/m2). NW, OW and OB were compared to identify potential differences in operating time, estimated blood loss, length of stay, complication, conversion, lymph node retrieval and margin status. Technique
Four ports were routinely used, with placement in the left upper, right upper, right lower and suprapubic positions. Occasionally a fifth port in the left lower quadrant was inserted to facilitate retraction of the colon when a bulky mesentery was encountered, particularly in obese patients. Lesions were confirmed by rectal or proctoscopic examination, as well as preoperative tattooing. The medial to lateral approach was utilized for our dissection and mobilization. The inferior mesenteric artery
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(IMA) was dissected and staple divided. The left ureter was identified, and the prescaral plane was carefully developed with preservation of the autonomic nerve fibers using the technique of sharp total mesorectal excision. The rectum was divided at least 3 cm distal to the tattoo using an articulating stapling device via the suprapubic port. The splenic flexure was mobilized as deemed necessary. A small 4 to 5 cm incision was then made for specimen extraction and proximal transection, and a circular stapler was used for all anastomoses.
Results Demographics
Twenty-six total patients; 15 male (57.7%) and 11 female (42.3%) with T3 or T4 rectal cancers are reported in this series (Table 1). They were categorized into NW (n = 7 (26.9%)), OW (n = 12 (46.2%)) and OB (n = 7 (26.9%)). The median ages (NW = 65 yr, OW = 63 yr, and OB = 66 yr) were also similar (Table 1). The median BMIs fo
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