Q. Hello Dr. C. My name is Michael and I live at Tybee Island. I am 62 years old and had a screening colonoscopy recently. A polyp was found and it had a small cancer in it. My doctor told me that not all the cancer could be removed at the time of the colonoscopy and that I should have a small segment of my colon removed surgically to be sure all of the cancer is removed. I have had several opinions regarding the type of surgery that is possible. One surgeon advised that I have the standard open procedure and another suggested that I have a laparoscopic colon operation. They both are well respected and I am confused. I need to decide and cannot wait too long. What do you think?

A. Good question, Michael. Welcome to the twenty-first century of surgery and its advances and challenges. Each year, some quarter of a million colon resections are performed in this country. Some fifteen years ago, following the lead of removal of the gallbladder by inserting a lighted tube through a small incision in the abdominal wall, surgeons removed a part of the colon containing the cancer through an additional relatively small incision and then sewed the remaining bowel in continuity. The procedure actually took longer than the classical operation of making a long incision and opening the abdominal cavity for wide direct visualization of the organs. That notwithstanding, patients had a day less recovery time in the hospital and had less pain following surgery. The cost of the minimally invasive or laparoscopic surgery was about the same as for the classical approach. While laparoscopic surgery for removal of the gallbladder has become the standard of care, such an approach for cancer inside the abdomen has been much more slowly accepted because of the uncertainties regarding the post-operative behavior of the cancer itself. For example, in the past decade there have been numerous reports of the cancer recurring in the small incision sites created at the time of the original operation. There has been a lingering fear that minimally invasive surgery may not be to the maximal benefit of the cancer patient. Also, the vast majority of currently practicing general surgeons have not been trained in minimally invasive colon cancer surgery. Most surgeons completing their training now on average have done probably only one or two such operations. In effect, colon cancer surgery training has remained unchanged for the past thirty or more years.

Recently, a study published in the New England Journal of Medicine has helped to clear the way for more rapid progress by reducing the concerns regarding the effectiveness of such surgery. In this study of some eight hundred colon cancer patients, half were randomly assigned to receive a classical open operation and the other half were treated with a minimally invasive approach. While one in five of the latter group had to be switched to the open approach for technical reasons decided by the operating surgeon at the time of surgery, several very important comparative observations were made during the post-operative period and as patients were followed for the next four years. The procedures proved equally effective in curing and limiting cancer recurrences. Both procedures are effective cancer operations. The minimally invasive procedure was proven to be associated with less hospitial time and with less need for narcotics. The classical procedure was required in twenty percent of cases chosen initially for the newer technique and was accomplished in significantly less operative time than required for the minimally invasive approach. In this study, the minimally invasive approach was avoided when the cancer was located in certain locations within the bowel and when it was judged to be extensive. Clearly, the minimally invasive approach is not the best approach for every case of colon cancer. On the other hand, this landmark study suggests that patients should seek a surgeon capable of performing minimally invasive cancer surgery and proceed with that approach if technically possible and clinically appropriate. We are fortunate to have several surgeons in Savannah who are well-trained in minimally invasive colon cancer surgery. A larger challenge for the country faces the medical institutions responsible for training our surgeons. The surgical training programs have much work to do if they expect to move quickly from teaching the surgical care of the last century to that expected for this century. You, as a patient and a consumer of healthcare resources, should expect to have access to the safest, most comfortable, and effective care possible.

I hope I have answered your question regarding what you should do regarding your particular serious but very curable condition. Let me know how things turn out. I, along with all the readers, wish you the very best of outcomes. >