title: Intraoperative technical difficulty during laparoscopy-assisted surgery as a prognostic factor for colorectal cancer.
abstract: BACKGROUND
  Laparoscopy-assisted surgery has technical drawbacks compared with open surgery, although laparoscopic surgery has become widely adopted with evidence of oncological safety for colon cancer treatment. The oncological risk of technical difficulties during laparoscopic surgery for colorectal cancer has not been previously reported. We aimed to investigate whether a technical difficulty encountered during laparoscopic surgery can be considered a recurrence-related factor for colorectal cancer.
  
  
  METHODS
  Data from 427 patients who underwent laparoscopic surgery for colorectal cancer between May 2003 and December 2007 were analyzed. An intraoperative technical difficulty was defined as a significant deviation from the ordinary surgical procedure. All conversions to open surgery and iatrogenic bowel perforation during laparoscopic surgery were included as technical difficulties. The Cox proportional-hazards regression model was used to evaluate the recurrence-related factor in the various risk factors including technical difficulty.
  
  
  RESULTS
  Technical difficulties were found in 44 (10.3%) patients, which included 17 (3.9%) conversions to open surgery and 10 (2.4%) with iatrogenic bowel injury. Technical difficulties were encountered more frequently in men compared with women (13.5% vs 6.0%, P = .013), and for cancers located in the mid and low rectum, splenic flexure, and descending colon. The recurrence rates were higher in patients with technical difficulties (local recurrence, 2.6% vs 6.7%, P < .05; systemic recurrence, 6.3% vs 13.6%, P < .05) with a mean follow-up duration of 45.9 months. Multivariate analysis by the Cox proportional-hazards regression model showed that a technical difficulty was an independent factor related to recurrence after laparoscopic surgery (odds ratio, 2.374; 95% CI, 1.006-5.600; P = .048).
  
  
  CONCLUSIONS
  This study has demonstrated that a technical difficulty during laparoscopy-assisted surgery jeopardizes oncological safety. It is suggested that surgeons should be prepared to minimize technical difficulties during laparoscopy-assisted surgery.
authors.affiliation: Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea. kangsb@snubh.org
authors.forename: Sung-Bum
authors.initials: SB
authors.lastname: Kang
authors.forename: Jun-Seok
authors.initials: JS
authors.lastname: Park
authors.forename: Duck-Woo
authors.initials: DW
authors.lastname: Kim
authors.forename: Taek-Gu
authors.initials: TG
authors.lastname: Lee
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D015179:Colorectal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007431:Intraoperative Complications; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology*; D009367:Neoplasm Staging; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome