Tumor Cell Dissemination during Laparoscopy: Prevention and Therapeutic Opportunities

Abstract

Port-site recurrences (PSRs) are abdominal wall recurrences that occur in the subcutaneous tissue within a trocar site after cancer laparoscopy and are not associated with peritoneal carcinomatosis. In order to develop PSRs, viable tumor cells must be liberated from the primary tumor, be transported to a wound, and find there a favorable environment for growth. The short clinical delay in the occurrence of PSRs and their size suggest massive cell seeding into the abdominal wall. Traumatic handling of the tumor, slipping of trocars, liquid projection, as well as poor extraction techniques can all cause implantation of malignant cells into the subcutaneous tissue. Such contact can also occur postoperatively if the trocar channels remain open. Some histologies (e.g. gallbladder adenocarcinoma), the presence of ascites and advanced tumor stage are risk factors for PSRs. Further conditions – including the use of gas – might also play a limited role. The first preventive measure is the correct indication for a laparoscopic approach. Several techniques have been demonstrated to prevent PSRs in the animal model: (a) fixation of trocars to the abdominal wall; (b) prevention of leakage; (c) careful specimen handling; (d) reducing trauma to the abdominal wall; (e) specimen isolation before extraction from the abdominal cavity; (f) trocar-site irrigation with a cytotoxic solution, and (g) closure of peritoneum. Further innovative therapies are currently under investigation. In the clinical setting, correct indication, surgical expertise and application of prophylactic measures seem to be the best way to prevent the occurrence of PSRs.

Surgical strategies in patients with gallbladder cancer: Nihilism to optimism

“…This hypothesis has gained support from the experimental studies which demonstrated that CO 2 insufflation, peritoneal injury, and other factors are [16,17]. During the laparoscopic procedure, if viable tumor cells are liberated from the primary tumor during manipulation, these cells get transported to the trocar sites by instruments/chimney effect and find an environment, which favors unrestricted growth, PSR will develop [18]. A review of literature from 1995 to 2002 revealed a PSR incidence of 0-2.5% [18].…”

“…During the laparoscopic procedure, if viable tumor cells are liberated from the primary tumor during manipulation, these cells get transported to the trocar sites by instruments/chimney effect and find an environment, which favors unrestricted growth, PSR will develop [18]. A review of literature from 1995 to 2002 revealed a PSR incidence of 0-2.5% [18]. In a comprehensive review of PSR reported in literature, 66% of reports were related to gastrointestinal tumors and 48% of PSR occurred after LC for unsuspected cancer.…”

“…Preventive measures to minimize this complication have been reviewed by Steinert et al [18] and include care of trocar sites by fixing and preventing leakage, careful specimen handling and isolation of specimen before extraction and reducing abdominal wall trauma and repair of the peritoneum. During LC especially in GBC endemic belts, gentle handling of the GB to avoid gross or micro perforation is critical in all patients, especially if there is pre-or intraoperative suspicion of GBC.…”

Laparoscopic Small Bowel Resection of Metastatic Pulmonary Carcinosarcoma

“…These include fixation of trocars to the abdominal wall, careful handling and isolation of the specimen prior to extraction, and trocar site irrigation with cytotoxic solution. 19 Furthermore, animal studies have demonstrated that port site peritoneal closure, the use of plastic trocars, and helium insufflation may decrease the risk of port site seeding. [20][21][22] In summary, this is the second reported case of pulmonary carcinosarcoma with metastatic disease to the small bowel.…”

A laparoscopic approach may be used to improve the surgical management of advanced ovarian cancer

“…During this initial laparoscopic procedure, the surgical rules designed to prevent trocar site metastasis should be applied [16][17][18]. As trocar site excision should be performed at the time of debulking procedures, the first and second trocar sites should be placed along the future midline incision and the lateral trocars should be inserted perpendicularly to the abdominal wall so that the scar may be reliably excised [11].…”