Minimally invasive surgery for colorectal cancer

Colorectal cancer is one of the most common types of cancer, particularly in developed countries, with a global incidence from 3.6 to 59.1 per 100,000 people [1]. The gold standard in surgery is radical resection of the tumor-laden segment of bowel with sufficient resection margins and removal of regional lymph nodes. Overall 5-year survival rates for colorectal cancer vary by stage from nearly 100% for stage I disease to approximately 50% if it has spread to lymph nodes (stage III) to approximately 5% if there is distal spread (stage IV) [2]. With the increasing use of screening programs for colorectal cancer, the aim is for earlier diagnosis and, thus, improved survival.

The conventional procedure of choice was traditionally open resection via laparotomy but the development of minimally invasive surgery has allowed laparoscopic resections to be performed and the first successful laparoscopic right hemicolectomy was in 1990 [3]. Despite this advance taking place 20 years ago, uptake has been relatively slow (unlike for laparoscopic cholecystectomy) owing to the cautious ongoing evaluation of the literature and concerns regarding cancer clearance. The short-term advantages of laparoscopic colorectal surgery for patients are great, with less postoperative pain, shorter duration of ileus [4], better lung function and reduced length of hospital stay [5]. Large randomized trials (Barcelona [6], Clinical Outcomes of Surgical Therapy [COST] [7] and Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer [CLASICC] [8]), Cochrane reviews [5] and meta-analyses [9] have shown that laparoscopic colorectal surgery is safe, associated with better short-term outcome and does not worsen long-term cancer survival.

Current research is focusing on developing surgical techniques that are even less invasive than conventional laparoscopic surgery to potentially reduce patient morbidity still further. These include single-incision laparoscopic surgery (SILS) and natural-orifice translumenal endoscopic surgery (NOTES). These techniques may indeed become the surgical techniques of the future but the treatment of colorectal cancer is a multifaceted approach. Research on training surgeons to become experts in these techniques is essential, as is the provision of a safe and efficient process to support and improve the quality of the patient’s journey. This includes more of a shift to fast-track surgery, and innovations, such as using lean six sigma methodologies, to improve performance and reduce the cost of cancer surgery provision.

Modernizing training techniques for surgeons

The increasing complexity of procedures and a tendency towards reducing the working hours of surgeons means that a change from the current apprenticeship model of training is needed. With an increasing population size and life expectancy, increasing change to a ‘Western lifestyle’, and screening programs leading to the earlier diagnosis of colorectal malignancy, the case load in colorectal surgery will increase. Methods of assessment that are objective [10] rather than subjective, such as checklists, global rating scales [11–12] and dexterity analysis [13] are needed. Methods of laparoscopic surgical training include live animal training, human and animal cadaver training, training using box-trainer (video-trainer) and virtual reality simulation models [14] so that surgeons can achieve a proficient level prior to operating on patients. Although video trainers are cheaper, allow the simultaneous training of multiple students to take place on an entire procedure and are more realistic than current virtual reality models, virtual reality can evaluate every movement using a computer and give instant feedback as a virtual tutor, in addition it does not need the assistance of a second person. Future developments could see a patient’s individual preoperative imaging imported into the virtual reality software so that training can take place on reconstructions of the actual procedure, thus incorporating decision making and anatomical variation [14].

In other high-risk industries, such as aviation, continuous assessment in simulators is an established part of training and this needs to be introduced into the surgical training program [15].

Integrating novel technologies & engineering & sciences research into care routines

With the ongoing desire to develop even less invasive techniques to enhance the benefits of laparoscopic surgery still further, the number and size of incisions have been reduced to a single umbilical incision in the case of SILS, and in the case of NOTES, skin incisions have been eliminated altogether. Surveys for cholecystectomy have shown that patients would generally favor NOTES to standard laparoscopy unless the risk is significantly greater, confirming the importance of cosmesis [16]. It is unlikely that this also holds true for the colorectal cancer cohort of patients. The first SILS cholecystectomy was performed in 1997 [17] and since then technology for imaging and port production has improved and colorectal cancer resections have been successfully performed in this way. Although SILS necessitates operating with reduced triangulation, the advantage of being able to use the same instruments as standard laparoscopy and also being able to insert another port if needed is not shared by NOTES procedures if it is to remain scarless. The first oral transgastric endoscopic appendicectomy in a human was presented but not published in India in 2004, and the procedure was performed transvaginally in 2008 [18], with the first transvaginal cholecystectomy in 2007 [19]. NOTES is still an experimental procedure with unproven risks and benefits, and is seemingly a progression from transanal endoscopic microsurgery but may represent the start of a shift in surgical mindset, such as that seen in vascular surgery with interventional radiology and endovascular approaches taking over from certain (open) operations.

Fast-track, or enhanced recovery after surgery, is a relatively new structured pathway designed to reduce the physical insult of surgery, aimed at maintaining normal gut physiology to enable quicker recovery and reduced hospital stay. The traditional practice was for all patients to have bowel preparation and be fully fasted, and postoperatively a nasogastric tube and gradual stepwise build up of oral fluids before commencing diet. Increasing evidence now shows that incorporation of key elements by the surgical and anesthetic teams (examples include preoperative counseling, no bowel preparation, prevention of hypothermia, epidural anesthesia and no routine use of nasogastric tubes, drains or morphine) can lead to faster recovery and reduced hospital stay [20].

Innovations in elective care & visions for improvement

Improvement in elective surgical care includes increasing patient safety, and improving team performance, theater efficiency and utilization time. The WHO surgical safety checklist is one intervention shown to reduce operative mortality and morbidity. The aviation industry has used a preflight checklist for many years and now a similar process is being used in the operating theater. There is a ‘sign in’, ‘time out’ and ‘sign out’ component to engage the entire theater team and it has been shown to reduce morbidity rates by a third (11.0 to 7.0%) and mortality rates by nearly half (1.5 to 0.8%) after introduction [21].

The process leading to a patient being diagnosed with colorectal cancer as an outpatient to having a range of preoperative diagnostic investigations to arrival in hospital for surgery to having surgery and recovering in the appropriate level environment, is intrinsically ineffective. Delays, repetition of work, cancellations and errors are not unusual. Lean and six sigma are methodologies to improve processes and reduce error and have been used in other industries for many years. Lean is an approach developed by Toyota in the 1950s to improve flow and eliminate waste (i.e., to do something more quickly and efficiently).

Six sigma on the other hand is a process improvement methodology developed at Motorola in the 1980s to reduce defects or error. Its focus is to highlight a problem and by its Define–Measure–Analyze–Improve–Control principle, to reduce variation. The aim is to reduce variation to within six standard deviations of the mean of a Gaussian distribution, leading to only 3.4 defects per million opportunities (0.00034%); one American study demonstrated a ‘defect rate’ in the quality of surgical healthcare at approximately 43% [22]. One example of implementing six sigma is in reducing the variability of ‘turnaround time’ between cases in theater to increase utilization and productivity, particularly if there are several shorter cases on a list [23]. Lean and six sigma can be used together – lean six sigma – to first aim to get a correct process and then reduce the variability (error) in that process as one of the tools to improve the quality of healthcare.

Conclusion

Minimally invasive surgery for colorectal cancer is shifting from being a novel option for a minority of patients in a few centers, to the mainstream. With improvements in technology the new frontier of procedures, such as SILS and NOTES has arrived, but precisely what role they will play in the future is yet to be determined by further research. With the addition of pioneering surgical techniques, innovations in training are essential as are steps to improve patient safety in hospital. Indeed, development of this together with enhanced recovery postoperatively and improving the process of the patient journey should result in a shorter stay, fewer complications and improved quality of healthcare.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.