40. Port Site Tumors: Means of Prevention

40. Port Site Tumors:

Means of Prevention

Marc A. Reymond, M.D.

Hans Lippert, M.D.

Morris E. Franklin, M.D.

“Tumor grafts in wounds are of particular interest for the surgeon. After laparotomy for malignant ascites, it is not rare to find small cancer nodules within drainage sites, on the contrary such findings are exceptional—if ever present—in laparotomy wounds.”

—Peterson, 1904 Possible means of prevention of port site recurrences have been identified on the basis of the contamination pathways and the local conditions identified in clin- ical observations and animal experiments. After reading this chapter, the reader should be able to understand the potential for the implantation of tumor cells into port site and other wounds during laparoscopic procedures. The reader should also gain knowledge of the prophylactic countermeasures that are avail- able to surgeons performing laparoscopic procedures.

The suggested means of prevention include preoperative measures, as well as technical tips to be applied before, during, and after tumor resection has been completed (Table 40.1). Collectively, these measures, when applied alone or in combination, should result in a lower incidence of port wound recurrences.

A. Preoperative Measures

Preoperative measures include proper patient selection, adequate training of the surgeon and of the operating team, and adequate surgical technique as well as complete and adequate equipment for advanced laparoscopic surgery.

Tumor infiltration into adjacent structures is present in about 10% of all col- orectal cancers. There is an increased risk of iatrogenic traumatization of such tumors, in part because these tumors are usually bulky and difficult to manipu- late laparoscopically. In locally advanced tumors, to adhere to accepted onco- logic principles, en bloc multivisceral resection with tumor-free resection margins is recommended. This type of resection for a locally advanced lesion is best performed via an open approach.

Traumatic manipulation of a tumor is one mechanism whereby viable tumor

cells may be shed during a cancer resection; however, in some patients, usually

those with advanced lesions, tumor cells may be spontaneously shed into the peritoneal cavity [3]. Regardless of how the tumor cells are liberated, once free- floating in the peritoneal cavity, they may give rise to a port wound recurrence or a local recurrence elsewhere in the abdomen [7]. In animal models that uti- lized tumor cell suspension models, the development of port wound recurrences appeared to be dose dependent [7]. In a review of all port site recurrences pub- lished after the introduction of laparoscopic colectomy, three-fourths occurred in patients with advanced tumor stages (TNM/Jass stages III and IV) [19]. Thus, in the opinion of the authors, large tumors that invade through the serosa or into adjacent organs are best not operated on using the laparoscope. This implies that all patients scheduled for curative oncologic laparoscopic surgery should be staged preoperatively with computerized tomography and, when indicated, endoultrasonography.

It is a known fact in surgery that the experience of the surgeon correlates directly with their results. Thus, a laparoscopic oncologic resection, in particu- lar when performed with a curative intent, should not be carried out by a surgeon with little minimally invasive experience; the same is true for an open cancer resection [8, 10]. In laparoscopic surgery, it is widely accepted that surgeons wishing to perform curative operations must first demonstrate minimally inva- sive proficiency by performing colorectal resections for benign indications [12].

Table 40.1. Suggested techniques for the prevention of port wound tumor recurrences.

Before resection:

Proper patient selection (exclude patients with very large lesions or lesions invading adjacent organs)

Adequate training and experience of surgeon and assistants Careful tumor localization (tattoo, barium enema, etc.) Proper port placement (position, angle, incision size, etc.) Anchor all ports (grips, threaded ports, or skin sutures) During resection:

Avoid gas leaks

Identify tumor-bearing segment (intraoperative colonoscopy if needed) Avoidance of direct tumor handling or manipulation

Sound surgical techniques

Respect of oncologic principles (closed resection, en bloc resection with lymphatic drainage, proximal vessel control, clearance of resection margin) Thorough irrigation and suctioning of abdomen

After resection:

Adequate-sized incision for removal of specimen Wound protector or specimen bag

Macroscopic and, if need be, microscopic analysis of resected specimen Thorough irrigation of ports and abdomen before closure (cytotoxic solution

or saline)

Fascial and peritoneal wound closure (for ports 10 mm or larger)

The location of the tumor must be precisely identified or the lesion con- taining the tumor clearly marked before the start of the operation. It is not rea- sonable to rely solely on the gastroenterologist’s impression of the location of the lesions with the exception of tumors at or within site of the ileocecal valve.

A variety of endoscopic and radiologic techniques have been described that serve to identify the tumor-bearing segment. Tattooing is the most reliable endoscopic method; India ink, the most widely used agent, results in a long-lasting and prob- ably permanent tattoo. Endoscopic clips are less reliable and remain cumber- some to use [6]. If these methods fail to definitively identify the tumor location, then intraoperative endoscopy must be performed. Colonoscopy can also be used if there is any question as to what constitutes an adequate margin of resection.

Tissue trauma has been shown to enhance tumor growth in experimental studies [1, 17], and clinical observations confirm the paramount significance of raw surfaces in the development of intraperitoneal and intrapleural recurrences.

Thus, parietal trauma should be minimized by proper placement of trocars;

ideally, ports should be placed so as to provide adequate access to the segment in question without requiring heavy torquing or levering of the port. Moreover, trocars should be placed perpendicularly to the abdominal wall to avoid tearing the peritoneum [2].

CO

leakage around trocars should be prevented. There is experimental evi- dence that tumor growth at trocar sites is enhanced in the presence of massive gas leaks [17]. Although a “chimney effect” has been postulated, the effect of gas leaks on port site recurrences is probably indirect, because it has been fairly well demonstrated that aerosolization of tumor cells (stable suspension of tumor cells in the CO

pneumoperitoneum) only occurs during grossly contaminated and prolonged surgery, and does not commonly lead to the seeding of port wounds [9, 13, 15]. Massive gas leaks, however, may transport tumor cells by propelling fluid microdroplets that contain tumor cells out of the abdomen and into the wound. Ports may also become contaminated during desufflation events;

these ports may seed the wound when they are removed at the end of the case.

Regardless of the precise mechanism by which CO

leaks facilitate port tumors in experimental models, such leaks can be prevented or minimized via a variety of measures. The incisions for ports should be carefully made so as to avoid an overly large skin opening that would encourage gas leakage. The use of some type of port-anchoring method will also prevent accidental port dislodgement and sudden desufflation (Figure 40.1A).

B. During Resection

We have shown that during oncologic surgery in animal models the instru-

ments often become highly contaminated with tumor cells [13]. Rinsing of the

tip of the instrument before its withdrawal is recommended (Figure 40.1B) and,

conversely, the extracorporeal cleansing or decontamination of an instrument

before its reinsertion is advised. The latter can be done by dipping the instru-

ment into a plastic bag partially filled with a cytotoxic solution off the surgical

field [11]. For example, the surgeon can use an iodine povidone (Betadine) solu-

tion, which has been shown to be tumoricidal in vitro, as well as in vivo, in most

Figure 40.1. (A) Laparoscopic port “anchored” to the abdominal wall with a conically shaped “port grip.” (B) Irrigation of laparoscopic port intracorporeally.

Irrigation should be followed by thorough suctioning of intraperitoneal fluid. (C) Removal of resected cancer via specimen bag. (D) Fascial and peritoneal closure of all ports 10 mm in size or bigger via a suture passer with port still in place.

studies [5, 14, 21]. Alternately, a solution of taurolidine can also be used.

Mechanical cleansing of the instruments by thoroughly wiping them should also reduce the chances of seeding port wounds by this mechanism.

During surgical manipulation, ports are progressively loaded with tumor cells, as shown not only in the pig model with radioactivity studies [16], but also

A

B

in the human setting [13]. Thus, trocar exchange, such as the introduction of a larger-diameter trocar via a smaller port wound, is prohibited in cancer surgery.

As mentioned above, port dislodgement should be prevented by making an ade- quate incision, by selecting well-designed ports, and by securely fixing the ports to the abdominal wall [14].

In addition to careful handling of the colon, resection must follow the same oncologic principles observed in open surgery, namely, en bloc resection with

Figure 40.1. Continued C

D

removal of the corresponding lymphatics, use of “no-touch” technique, proxi- mal transsection of blood vessels, adequate bowel and mesenteric margins, and avoidance of intraoperative tearing or perforation of the tumor [12].

Spillage of colonic contents into the abdominal cavity should be prevented.

It is important to achieve proximal control of the colon with intracorporeal intestinal clamps (bulldog clamps or other noncrushing clamps) and to ligate the open end of the resected colon immediately after the colon is divided (if a totally intracorporeal technique is being used) or to divide the colon intracorporeally with a G.I.A.-type (Gastro Intestinal Anastomotic) linear stapler [2].

Tumor cells are carried across and through the peritoneal cavity by peritoneal fluid currents. These peritoneal fluids, including ascites and blood, are influenced by physical factors, such as the position of the patient, the laparoscopic instru- ments, and also by gas flow [16]. Ports, at the end of a cancer resection, have been shown to be highly contaminated with tumor cells, as already mentioned [13]. Circumstances in which the port site is brought into contact with peritoneal fluid (such as desufflation for smoke removal or during port removal) facilitate wound contamination with tumor cells. Ports should be thoroughly irrigated prior to being removed at the end of the case.

Sodium hyaluronate carboxymethylcellulose-based bioresorbable membrane (Seprafilm), used to prevent adhesion formation, has not been shown to affect the rate of tumor implantation at abdominal wound sites [18].

C. After Resection

After resection is an important time in a laparoscopic oncologic resection because most mistakes appear to occur at this point [2]. Most surgeons remove the specimen through a small abdominal wound. The wound used to extract the tumor should be protected in some manner. If the segment being resected has been fully detached, then the specimen is best placed in a plastic specimen bag, which is then tightly closed and then pulled out through the wound (Figure 40.1C). If the bowel segment remains attached at one end, usually the proximal end in the case of left or sigmoid colectomy, then it is not possible to put the entire specimen in a bag. In this case, a wound protector should be employed that will prevent contamination of the wound during removal of the tumor. Some advocate the use of both a bag and a wound protector. The incision should be large enough to allow a smooth extraction of the specimen. Another option, which avoids the “assisted” incision altogether, is to remove the specimen transanally [2]. In this case, the specimen must be fully detached and placed into a bag that is then pulled out via the anus.

Immediately after extraction, macroscopic assessment of the specimen should be performed by the surgeon himself, and frozen section analysis of the resection margins by a pathologist is strongly advised if there is any question as to the completeness of resection.

There is some evidence that closure of the port site’s peritoneal wound might

be of importance in preventing local recurrence (Figure 40.1D). In an experi-

mental model, repair of injured peritoneum at port sites reduced the frequency

of wound metastases in laparoscopic surgery for gallbladder carcinoma [1].

In an experimental model, excision of the laparoscopic abdominal port wound sites significantly, but not completely, reduced the wound tumor implan- tation rate compared with simple wound closure [20], suggesting that port site contamination occurs after completion of the surgical procedure, perhaps by tumor cell-containing peritoneal fluids. This rather drastic measure has not been utilized in humans thus far; however, these data do behoove the surgeon to make an effort to reduce the chances of port wound contamination. Thus, before extraction, the trocars inside the abdominal cavity should be thoroughly irrigated with a cytotoxic solution to kill any viable tumor cells that may be present [2, 14]. In the case of dilute poviodine irrigation, it is important to thoroughly irri- gate the abdomen with saline after the poviodine has been allowed to dwell for several minutes. The abdomen should be desufflated with the ports in place to avoid creating a chimney effect through a port site. The previously placed fascial sutures are immediately tied to avoid spillage of abdominal liquid through the port wounds. Irrigation of the subcutaneous tissues of the port and extraction wound with a dilute Betadine solution or other tumoricidal solution before skin closure is also advised [2].

If the surgeon decides to drain the abdomen when performing laparoscopic cancer surgery, a closed suction device is highly recommended. Capillarity- based drains will lead to a contamination of the wound.

D. Conclusions

Port site tumor recurrences are a potential complication of laparoscopic col- orectal cancer surgery. In the final analysis, they have to be considered local recurrences. As is the case with other intraabdominal “local” tumor recurrences, the surgical technique utilized and the surgeons themselves are important vari- ables. Wound tumor recurrences, in many instances, are probably the aftermath of poor surgical technique. However, the biology of the tumor likely also plays an important role [4]. It is hoped that after studying this chapter the reader understands the potential for the implantation of tumor cells into port-wounds associated with the various steps of a laparoscopic cancer resection. It is further hoped that the reader will adjust their technique so as to make use of the prophylactic measures that are believed to reduce the chances of port wound tumor formation.

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