laparoscopy in abdomen malignancies

1. ROLE OF DIAGNOSTIC LAPROSCOPY IN
ABDOMINAL MALIGNANCIES
Moderators: Dr.Neeti Kapur
Dr.Nikhil Gupta
Presenter:Dr.Parikshith.M

2. Introduction:
• Accurate cancer diagnosis and staging are crucial to determine the
efficacious treatment plan for the patients with malignancy.
• To avoid unnecessary laparotomies in the nonresectable group.
• Laproscopy reduces the discrepancy by accurately assessing the
disease extent.
• To differentiate the one who needs palliative therapy from the one
who needs complete resection.

3. Technique:
• Staging laparoscopy alone can be performed with very low morbidity,
often with same-day discharge.
• Pneumoperitoneum is established using an open or veress technique,
and a 30° angled laparoscope is introduced.
• Two 5-mm trocars are placed in the right upper quadrant and these
may be exchanged for 10-mm trocars if a feeding jejunostomy or
gastrojejunostomy is subsequently performed.

4. • A systematic, 360° inspection of the abdomen is performed,
beginning with the liver and including the peritoneum, omentum, and
entire bowel mesentery.
• Systematic examination beginning in the right upper quadrant
• Appropriate positioning intraop to visualize different quadrants.
• A more extensive examination can be performed by entering the
lesser sac by incising the hepatogastric ligament.

5. • With the patient in neutral position ,the omentum can be reflected
upwards to expose the transverse colon.
• Transverse colon is elevated to expose transverse mesocolon and
ligament of treitz which are sites of potential lymphadenopathy and
locally advanced cancers.
• Small bowel examined from the ligament of treitz to IC valve will be
done.
• Trendelenberg positioning to visualize the pelvis and inspecting the
colon.

6. • Biopsies are obtained of suspicious lesions and sent for pathological
examination.
• Biopsy of the primary tumor is generally avoided because of the
theoretical risk of intraperitoneal dissemination.
• If no visible evidence of metastasis is present, 1 to 2 liters of saline
are instilled, then collected for peritoneal cytology.

7. Metastasis over subdiaphragmatic surface and liver:

8. Ovarian mets in Ca.stomach:

10. Laproscopic ultrasound
• High-frequency sonographic probes have been designed to be passed
through laparoscopic and thoracoscopic ports to help the surgeon
during the procedures.
• The surgical technique and decison-making can therefore be altered
according to the information provided by intraoperative imaging.
• With laparoscopic US, high resolution images can be obtained of the
biliary ducts, the gallbladder and the abdominal parenchymas
without the image degradation caused by overlying bowel gas or a
thick abdominal wall.

13. • laparoscopy is accurate in detecting peritoneal deposits and small
superficial liver metastases .
• It’s efficacy is limited by the inability to reliably assess lesions deeply
located in the liver parenchyma or in the retroperitoneum. These
limitations can be overcome by the use of laparoscopic US.
• The depth of sound penetration with 7.5 MHz transducers is
approximately 7–8 cm

14. • The surgeon subsequently raises the gallbladder anteriorly; the probe
is placed directly onto the hepatoduodenal ligament and gently slid
toward the duodenum and the pancreatic head.
• These steps allow for the investigation of the CBD in its entire length,
down to the region of the papilla.
• A relatively new application of intraoperative US is the possibility to
perform interstitial therapy of liver tumors at the time of the initial
surgery.

15. • This can be useful, for example, in patients undergoing liver resection,
when another deep or unresectable lesion is found in another
segment or in the contralateral lobe.
• While the resectable tumor is removed, the other lesion can be
treated by thermal ablation with radiofrequency or laser probes
placed directly under US guidance.
• The lesion detected can also be biopsied under laparoscopic US
guidance.

16. • Laparoscopic US has been proposed as an alternative to operative
cholangiography.
• Laparoscopic US is particularly useful in evaluating vascular
infiltration.
• Signs of tumor invasion are thrombosis of a vessel, luminal narrowing
and loss of the hyperechoic interface between vessel and tumor with
or without the tumor actually protruding into the vascular lumen.

17. • Another potential field of application of laparoscopic US is
represented by endocrine pancreatic neoplasms.
• laparoscopic ultrasound was able to detect the tumors and to
accurately depict their relationships to the Wirsung’s duct, the splenic
artery and vein.
• Small islet cell tumors may not be palpable at operation and can be
identified in up to 85–100% of cases by intraoperative US.

18. • In patients undergoing laparoscopic segmental resection of the colon
for malignant neoplasm, laparoscopic US can be performed to detect
liver metastases and to localize the segment to be resected.
• The surgeon uses laparoscopic US to localize lymph nodes which were
seen at preoperative CT but are deeply seated and cannot be seen at
laparoscopy. This localization reduces the time necessary for surgical
dissection.

19. • TNM staging of gastroeophageal cancer takes advantage of the use of
laparoscopy for the detection of occult metastases and of endoscopic
sonography for T and possibly N staging. Laparoscopic US may
combine the strengths of both techniques.

20. Pancreatic Malignancy:
• Laproscopy can clarify the situation in the patients who have been
deemed resectable by endoscopic usg and CT, by differentiating
reactive from malignant lymphadenopathy and visualize peritoneal
and small liver implants missed over CT.
• The operability rates were as low as 45% during laparotomy in the
patients who were considered as operable by routine diagnostic
methods.
• Kocherization allows for evaluation of retroduodenal tissues.
• Evaluation of retropancreatic tissue is challenging due to superior
mesenteric artery and vein. This can be overcome by laproscopic usg.

21. Transverse scan through the pancreatic head shows a 2-cm
hypoechoic pancreatic ductal adenocarcinoma (T), adjacent to the superior
mesenteric vein (SMV) (arrowheads). A thin rim of tissue is
visible between the tumor and the vessel, and the tumor does not
invade the superior mesenteric vein. The superior mesenteric artery
(SM) is clearly free of tumor.

22. • Therefore with advanced pancreatic malignancies dynamic CT with
diagnostic lap and laproscopic USG is the optimum line of evaluation.

25. Hepatobiliary Malignancies:
• Carcinoma of gall bladder and extrahepatic cholangiocarcinoma are
detected at a very late stage and most patients are found to have
occult distant meatastasis during laproscopy.
• As the median of survival is less than 6 months and endoscopic
palliation will offer a better quality of life than a non therapeutic
laparotomies.
• The yield of staging laproscopy is very high in these malignancies and
should routinely be used.

26. • More than 2/3rd of the patients undergoing exploration are deemed
unresectable in hepatocellular malignancies.
• Memorial Sloan-Kettering Cancer Center-Staging laproscopy with
LUSG avoided laparotomies in 20% of the patients and almost 90% of
the patients undergoing laparotomy were offered complete resection.
• Non cirrhotic patients are more likely to benefit bfrom this than the
cirrhotic ones.

27. Esophagus and Gastric Malignancy:
• Selection of the patients for surgery is based on CECT and endoscopic
USG.
• However occult abdominal metastasis have been missed.
• In a study conducted by Smith et al, it was demonstrated that
laparoscopic staging detected unsuspected metastasis in 40% of the
patients who were otherwise considered inoperable.

28. • When performed as a separate procedure it has the disadvantage of
the additional risks and expense of a second general anesthetic.
• However, separate procedure laparoscopy allows the additional
staging information acquired at laparoscopy (including the results of
peritoneal cytology) to be reviewed and discussed with the patient
and multidisciplinary treatment group prior to definitive treatment
planning.

30. • Palliative procedures such as gastrojejunostomy and feeding
jejunostomy can be done in the same setting in inoperable tumours.
• Second look laproscopy can be done after neoadjuvant chemotherapy
in a case of locally advanced unresectable disease.
• A definitive correlation between the stage of the disease and positive
cytology was noted in the patients of carcinoma stomach.

31. • In a study conducted by Nath et al, it was demonstrated that therev is
no difference in survival between patients with macroscopic
metastatic disease and only positive cytology.
• This led them to conclude that curative resection should not be done
with the ones have positive peritoneal cytology.

32. Colorectal Malignancies:
• No role in acute obstruction.
• In asymptomatic patients it is used to identify the peritoneal and liver
metastasis that would be best treated with chemotherapy.

33. Disseminated intraperitoneal malignancy:
• Diagnostic lap to be performed prior to cytoreductive surgery with
HIPEC.
• Laprotomy should be avoided if the peritoneal carcinomatosis index is
>19.

35. Photodynamic laproscopy:
• Photodynamic diagnosis using 5-aminolevulinic acid may
improve gastrointestinal cancer diagnostic accuracy.
• 5-aminolevulinic acid (5-ALA) is an intermediate substrate of
heme metabolism.
• The administration of 5-ALA to cancer patients results in tumor-
specific accumulation of protoporphyrin IX (PpIX), which emits
red fluorescence with blue light irradiation.

36. Photodynamic blue filter:

37. Endoscopy assisted laproscopic surgery:
• EALS for gastric tumors was first introduced in 1999 by Aogi
et al.
• Initially, endoscopy was used primarily as an “extra set of eyes”
allowing better localizing of the tumor and recent studies have
combined ESD with LS with excellent results .
• Benefits of a combined approach include better localization of
the tumor, determining the best laparoscopic approach,
verifying complete resection, ensuring adequate margins.

38. Take home points:
• Diagnostic laproscopy when combined with laparoscopic ultrasound
reduces postop morbidity by avoiding laparotomies in unresectable
tumours.
• EALS further increases the yeid.