Myths in management of colorectal malignancy

Laparoscopic colorectal resection has become increasingly popular for benign disease of the colon and rectum, bur there is still controversy about laparoscopic colorectal resection for potentially 'curable' malignant disease, While the antagonists of laparoscopic colorectal resection for malignant disease urge fellow surgeons and ethics committees to reject the introduction of laparoscopic surgery in malignant conditions, the protagonists state that laparoscopic surgery is applicable to many of the operations performed in colorectal surgical practice. Siewert and Feussner(1) stated in 1994 that the place of laparoscopic techniques for malignant disease can be best estimated if surgeons concentrate on the so-called 'oncological standards', According to Leape(2) the criteria for standards in medicine should be thoughtful and rigorous: benefit should be obvious and it should be established by scientific studies, However, whether at present there are any proven and useful oncological standards in colorectal surgery may be questioned. Siewert and Feussner(1) demand that the following oncological rules must be followed: wide tumour resection with gentle tumour removal, en bloc resection of the tumour without tumour cell spillage, no-touch isolation technique, primary ligation of the vessels and systematic lymph node dissection. This paper questions whether these demands are justifiable on the scientific evidence, There seems no doubt that total tumour clearance is essential to ensure maximum survival. Furthermore, it has been shown that tumour disruption before or during the operation worsens survival(3). Therefore err bloc resection is logical and nobody would willingly 'massage' a tumour during operation, However, the proof of evidence to support some of the other 'essential' rules is doubtful.